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In 1952 John Horder published an essay in the London Hospital Gazette, entitled 'The opinions of Sir James Mackenzie'.1 He had recently completed his post as medical registrar at the London Hospital and joined Dr John Wigg in his general practice in Kentish Town. Mackenzie, widely regarded as one of the fathers of modern cardiology, and founder of the London Hospital's cardiac department, was also a general practitioner. Based on his reading of Mackenzie's writings, Horder eloquently argued the case for the preservation of medical generalism in an age of growing specialization, and outlined the role of the general practitioner as clinical teacher and researcher. What concerned him was the wide perception of a professional hierarchy in which the general practitioner was accorded inferior status to that of the hospital specialist. This, he feared, would inhibit progress. He wrote: '[the general practitioner] has not yet set up his special heroes as the physician has set up his Osler, the neurologist his Charcot, and the surgeon his Astley Cooper. This is still to be done'.
More than 50 years later, general practice has found its heroes, and John Horder stands in the first rank of these. He is, I suggest, a surprising one. Heroes in the Homeric sense possess superhuman qualities of courage, strength and abilities. They are larger than life. Horder has human qualities and he is life-sized. In this he redefines the heroic in terms of the humane medicine that he represents.
When the editor of this journal invited me to write this appreciation, I was at once aware that, despite many years of friendship and professional collaboration with John Horder, I was not yet ready for the task. As literary portrait painter, I needed now to arrange a number of 'sittings' with my subject. This we agreed. What follows is a personal reflection on the conversations that followed, as well as my recollection of so many previous discussions with him down the years.
The first sitting sets the scene. I walk up the steps of a house in Primrose Hill and knock loudly. After a minute or two his wife Elizabeth opens the blue painted front door. Her viola is still tucked under her chin: a string quartet is rehearsing in the ground floor front room. John comes down the stairs to lead me to the first floor sitting room, where the grand piano stands always open. The available wall space in the tall house is hung with original paintings—many are his own watercolours of the French and Spanish churches and countryside that he loves.
I was led to a window seat overlooking the hill which is one of London's loveliest open spaces. 'I need to be able to look out on a view like that,' he said. It is 37 years since I made my first visit to this room and sat in this chair. We talked about the nature of medical generalism and his concern that doctors attend at one and the same time to the patient's body and the patient's mind. At that time he was chair of the Royal College of General Practitioners Vocational Training Committee, and was about to guide the College through a period of unprecedented and radical change in our thinking about the tasks of the general practitioner, and the necessary training for it.
In 1967 I had undertaken a review of the training-cum-research seminars pioneered by Michael Balint at the Tavistock Clinic. Balint had urged me to go and see 'this very important man'. In preparation, I went to hear him give the second William Pickles Lecture2 at the RCGP Spring Meeting at Cambridge. It inspired me. I had never before heard a professional leader speak with such authority about the relevance of the arts to the science of medicine, and about the intricate interplay between the patient's life and illness.
Time and again, over the past four decades, we have sat together in this same room, in these same seats, and returned to these same key themes. In that time medicine's technical advances have been spectacular. The NHS has been iteratively reorganized in the attempt to cope with the cost and complexity of new technology, additional morbidities, an ageing population, and the escalation of expectations. All of this could perhaps have been predicted half a century ago, when Horder wrote his essay about Mackenzie. What could not then have been so confidently predicted was that, in counterpoint to the spectacular advances in specialist practice, the clinical perspectives and skills of generalist practice would be as impressively transformed. For many of us, John Horder was to become a key figure in this transformation.
In 1950 a visiting Australian doctor, JS Collings, had published a damning indictment of general practice in his Lancet report 'General practice in England today.'3 This painted a dismal picture of overworked practitioners, inadequate, often shoddy, premises, poor clinical standards, and widespread disillusion. From its inception in the succeeding years the newly created College was to foster a flowering of research, education, service innovations, and quality of care.
The College's success in this was in large part due to its openness to innovation and experiment. This openness to radical ideas and people was Horder's particular gift to the College at the time, a gift all the more surprising because of what I believe to be his innate academic, aesthetic, and in many ways social (though not political) conservatism. His painting is representational, not impressionistic, let alone 'abstract'. He prefers Bach to Beethoven; Pissaro to Picasso. I remember him chairing a College meeting some 30 years ago. An unorthodox approach to clinical teaching was being advocated. He endorsed the experiment, but, mindful that novelty is not necessarily progress, took comfort with the observation 'Thank God we are a conservative profession'.
In 1954 Stephen Taylor published Good General Practice,4 a counterblast to Collings' critique. Taylor, whose background was in public health and administration, was primarily concerned to find examples of excellent practice, and his perspectives were largely epidemiological and organizational. In consequence he had a rather technomanagerial view of the tasks of general practice. Not least, he derided the psychologically oriented clinician. The book was much discussed at the time, and in many ways influenced the growing ambitions of practice. Although not in conscious opposition to Taylor's values, John Horder became a leading figure in the moderation of this overly managerial and instrumental vision, into one that focused on the clinical encounter. Here serious and simultaneous attention was to be given to the physical, psychological, social and (in the broadest sense of the word) spiritual aspects of the patient's problem.
The key to this integrative approach was the constant search for appropriate balance. Another, was his preferred way of working; '... throughout my career I have invariably worked in groups'. In 1969 he convened and chaired a small College working party to advise on the content and methods of vocational training. Their report was published in 1972 as The Future General Practitioner.5 It set new goals and new approaches which were to stand for almost three decades. As chair and leader of this group he brought authority, his signal sense of the balance between conflicting goods, and his instinctive feel for what might be an acceptable pace of change. The book became immediately influential, not only in the UK but abroad. It set the agenda for the European Leeuwenhorst Group of which he was Honorary Secretary from 1974 to 1981. This surprising international acceptance of what was a truly radical and controversial programme came about in no small measure because of the trust that the profession had come to place in John Horder's judgment.
His formal education had been marked by a succession of changes of mind. His elder sister was a classicist who became a classics tutor at Cambridge, and until the age of 19 his education had been entirely in the humanities. He went to Oxford as an open classical scholar but spent all his vacations in Paris, where he studied music.
'Although I have great respect for science, the rigour of scientific thought, the excitement of its counter-intuitive insights, I have never thought of myself as a scientist. Basically I am an artist from a family of artists. My father was a frustrated artist (he was a quantity surveyor who wanted to be an architect and artist); my mother was a professional violinist; my other sister was an artist; my wife is a viola player; my daughter is a professional cellist, and two of my grandchildren are currently studying at colleges of music.'
He had hoped to become a professional pianist and organist, but gave up this ambition when he was told by his teacher in Paris that he would never be in the first rank. Music continues to be a central part of his life; he remains a serious and accomplished performer.
He ascribes his decision to change from classics to medicine to two interlocking influences—the prospect of war in the late 1930s, and the desire to learn more about human nature. At school he had been strongly influenced by a number of charismatic teachers with deeply held pacifist convictions. This pacifist inclination conflicted with his sense of patriotic duty and his opposition to the Nazi aggressions in Europe. Doctors, he thought, would not need to feel so conflicted. Today he believes that this thought was an important background consideration, perhaps unconscious at the time, in his decision to change courses. In the event, and before he started his clinical studies, the onset of war supervened and he was to serve as an officer in a combat regiment.
Starting at Oxford in 1938, he became disenchanted with classical studies and developed an interest in philosophy and psychology. University College Oxford was, he says, 'full of economists', most notably Sir William Beveridge. He thought then that economics was 'all about money', but says that later he came to the view that economics was actually about human nature. This is what interested him. 'I formulated the idea that I should like to study human nature. My classics tutor sent me to talk to the medical tutor, who suggested that if I wanted to study human nature I should first study its pathology by changing to medicine.' This he did, and was for the first time exposed to the study of sciences. Again he became dissatisfied. 'Compared with my previous grounding in the Greek and Latin classics, I found the study of medicine intellectually unsatisfying, and wondered if I might have made a mistake.'
Concerned to study human nature, he assumed that this would lead to a career in psychiatry. To this end, while still at Oxford, he underwent a Jungian analysis. Jungian because, coming from a strongly nonconformist Christian background, he was at once attracted by the spirituality of the Jungian approach and perhaps uneasy with the sexual preoccupations of the Freudians. But his analysis left him unconvinced, and he quit after 2 years. The goal of psychiatry faded.
At The London as a student, already married and with two children, he often felt critical of the manner in which clinical medicine was then being taught and practised. 'I felt an alien in medicine'. Chance, which had played so large a part in his eventual choice of profession, now led him to the career that was to become his life's work.
In 1951 he worked as a locum in the Wigg practice at Kentish Town. Later he joined as a partner. Here at last he found the freedom 'to study human nature' outside the boundaries of clinical institutions, and to engage with it as a doctor. In the practice he found colleagues to respect, and to whom he could relate. But in the profession at large he continued to feel 'an alien'. For a short time he had been chair of the local Division of the British Medical Association. 'I was shocked by the cynicism, the concern with money, the endless grumbling. I saw behaviour among my fellow doctors that was deeply disturbing'.
In 1952 he became a Foundation Associate of the new College of General Practitioners. Here, at College meetings he encountered colleagues from every part of the country who shared his idealism and vision, and he threw himself into College activities. The College activists were small in number, large in ambition, and tireless in their efforts to change the culture, to give voice to a new spirit of enterprise, excellence and optimism in general practice.
The pressures of a busy practice (his patients seem to have been substantially drawn from the Hampstead intelligentsia and must have been very demanding), and the egregious volume of College work in the 1950s, both contributed to Horder's first serious episode of depression. Personal illness is a great teacher of doctors. He says that it was not psychotherapy but the exhibition of mono-amineoxidase inhibitors that helped most.
Yet his understanding of his depression reflects a truly generalist clinical philosophy. Although the successful treatments have been physical, this does not obscure his view of the origins of his depression, the social as well as the genetic inheritance, the parts played by the chance of events. 25 years ago, when he experienced a coronary thrombosis, he told me that the physical pain was remarkably similar to the physical pain of severe depression. If anything, he found that the latter was actually the more overwhelming.
This sense of balance between the different components of illness is of the nature of his definition of clinical generalism. He was a member of the first Michael Balint training-cum-research seminar at the Tavistock. In 1957 that research was reported in Balint's influential The Doctor, His Patient and the Illness.6 Horder parted from Balint and the group after only 2 years (the norm for participation was far longer). I think he found it difficult to come to terms with Balint's psycho-analytical detachment. Balint could be both too much and not enough of a father figure to his general practitioner colleagues. The more proximal reason Horder gives for his disaffection is that he could not accept Balint's out-of-hand rejection of any physical aetiology in mental illness. Again, equipoise between conflicting theories, between a science-driven physical approach and an arts-based psychological approach, lies at the heart of his clinical philosophy. For a man who so values reason and restraint in the presentation of self, Horder can nonetheless show toughness and passion in his defence of the reasonable.
Spirituality is at the heart of his thinking and motivation. He speaks of the 'sacredness of ideals'. Here again there is a paradox. Christianity was an important part of his family's life. From the age of 12 he was a boarder at a high Anglo-Catholic school, and attended church twice a day. The man who most profoundly influenced him was the grandfather who died only a year after he was born. Garrett Horder was a nonconformist minister, and his powerful personality, imagined not recalled, 'threw a long shadow'. Garrett's godlike image, a tall bearded figure, wise, kind, came to represent his grandson's deepest sense of right and duty. Yet Horder describes himself as an agnostic. In 1996 he was invited by the editor of the Proceedings of the Royal College of Physicians of Edinburgh to write about his belief.7 In this essay he rejects the notion of the Judaeo-Christian God, personally concerned to judge and intervene in individual lives, and sets out the humanistic basis and boundaries of his own belief. He writes, '... medicine, with its exacting ideals of truth to reality and service to others, has allowed me a certain substitute for religion in its contemporary Christian form'.
John Horder's demeanour is essentially reserved, his speech measured, his expression reflective. He holds humility to be an important virtue and he is a superb listener. As a child he was taught that 'showing off' was bad form. Yet his ambition has taken him to the forefront of his profession, including the Presidency of his College and many high honours. It is another paradox that despite his protestation of humility, status matters to him. Not personal status, but that of clinical generalists in relation to specialists. In 1950, the founding of the College of General Practitioners was vehemently opposed by the older Colleges. A significant opponent of the ambitions of general practitioners was Lord Horder of Ashford, physician to five successive British monarchs from Edward VII to Elizabeth II, and John's distant cousin. John Hunt, co-founder of the College and its first honorary secretary, had written to him to ask his opinion on the formation of either a College or a Faculty. Lord Horder replied that he favoured neither. This slight must have stung the young Horder. The family was one of conspicuously high achievers, in which Lord Horder himself was a towering figure. Although in no way intended—indeed, Lord Horder later withdrew the remark and apologized—I suspect that the slight was nonetheless felt to be personal as well as general. John's subsequent concern to defend general practice in the face of indifference from the branches of the specialist profession may well have been spurred by the disappointment of that rebuff.
In his 1977 Royal College of Physicians lecture 'Physicians and family doctors: a new relationship', Horder argued the moral and intellectual equivalence of the two branches of the profession. In this, as in so much else, he has proved to be general practice's most articulate ambassador, and its most persuasive advocate.
This ambassadorial role extends far beyond the UK. is the first UK general practitioner to have been appointed World Health Organization Consultant. He has visited almost all Western European countries, holds numerous honorary memberships of their general practice academic institutions, and was recently hailed, to his acute embarrassment, as 'the Pope of Portuguese general practice', in the renaissance of which he has played a key part.
This appreciation is neither a biography nor, thankfully, an obituary, and it is far from complete. I have picked and chosen from a wealth of his contributions to medicine, and have omitted much—for example, his chairing of the College's groundbreaking working parties on preventive medicine,8 his contribution in founding, in 1984, and subsequently chairing, the UK Centre for the Advancement of Interprofessional Education.
At our first sitting John said 'What place is there contemporary life for someone who is committed to three or four different fields of activity? I have never been expert—as thinker, writer, doctor, musician, artist. Yet believe that society needs such people'.
His life so far has vindicated that belief. As approaches his 85th birthday, John Horder remains vigorous and as intellectually stimulated and stimulating ever. This has been a personal portrait. I offer it as celebration, an expression of the gratitude of the profession, and a token of personal affection.