Learning from the vespertine doctors

and, at the final act, he had lifted

his stethoscope to listen as if to Mozart.

Then, silently, relatives and friends filed out.

No applause. None for Hippocrates’ art

From: Portrait of an old doctor by Dannie Abse ¹

In the waning light of dusk some things become more active: the barn owl begins its nightly hunt, the flowers of the South American Moonflower open. For some doctors, also, the twilight of their careers is a time of blooming. Their ‘literary flowers’ open with their laptops and they begin to write about Medicine.

What should we make of these physician-authors, of their motives, memories and perceptions? If they still possess the capability to practise, and sufficient interest in their profession, why put down the stethoscope to take up the pen? Should today’s clinicians bother with the words of yesterday’s men and women? For, what is there to learn from those who ‘rage against the dying of the light’ ² other than that they are enraged and that for them, wise or good, wild or grave, the light is dying? Better perhaps they should sit on their hands than take to the keyboard; keep their thoughts to themselves. We could reassure them that already they have gained the respect, the veneration even, of colleagues through the longevity of their practice. Simply put, they have done enough.

Neither the state of Medicine, nor the morale of its present practitioners, are likely to be improved by another memoir from an erstwhile physician, now more likely to be a patient than to see a patient, bewailing the passing of a simpler but more enjoyable age, an age of deference, hard work and honour. Because if they insist, if they must write, there is a danger that they will produce a saccharine story. Such a ‘hymn to their common past, a sentimental summary of an unsentimental story that was disappearing’ (p.83) would be partial and therefore unreliable, downplaying difficulties and ignoring inconvenient truths – ‘In the sunset of dissolution everything is illuminated by the aura of nostalgia, even the guillotine’ (p. 4). ³ Doubtless a suitably designed observational study of physicians would show increasing age to be an independent risk factor for excessive wistfulness and loud self-justification. Why is this?

At its core, growing old is characterised by a loss of elasticity, an inflexibility of both body and mind. In the aging lens this causes a presbyopia so severe and progressive that the elderly doctor, wishing to examine their experiences, must hold them at an ever-greater distance until they can only be appreciated through an obligatory pair of spectacles. These are almost inevitably of the rose-tinted variety. This explains the type of ‘back-in-my-day’ reminiscence that does nothing to nurture inter-generational solidarity.

Nor is this a recent phenomenon. According to the American bio-ethicist Ezekiel Emanuel, ‘at the end of their careers physicians tend to wax poetic about the art of medicine and how it is being lost (the same art seems to be lost every generation)’. ⁴ Emanuel’s parenthetical qualification suggests that this recurring sense of loss is misplaced; that doctors in their pre-dotage cry, ‘Wolf!’ If he is correct, then the art of medicine, however endangered it may seem, has never been lost. Rather it has persisted over the years, ever-present while individual physicians come and go, and grieve it on their way.

Accepting that this habit of the aging doctor-author, to eulogise their beloved ‘art’, tells us something of the nature of professionals, namely their inclination to shout out during the diminuendo of their calling, as they seek meanings – ‘What was it all about?’ ¹ – we should not dismiss too easily the subject of their concern. To consider their writings is to learn not only of them but of Medicine itself.

They write with a sense of loss but also from a position of being lost. These doctors have witnessed substantial changes over their ‘professional lifetimes’. Once-lauded technical and scientific advances have been superseded; ‘facts’ memorised then disproved. Much dogma has been overturned, new disorders named and renamed, new regulations published and revised, new management systems established and reworked. Now they realise that ‘Yesterday’s revolution was today’s routine practice and tomorrow’s out of date ways of working’. ⁵ They mourn the passing of the welcoming familiar practice they entered all those years ago and the innocent confidence they then possessed. It was in that practice that they expended so much of their energies. They offered it commitment, but it proved unfaithful and grew remote. They have been left behind by progress, increasingly outmoded and outmanoeuvred.

Bewildered, they cast around for solid ground, something recognisable, and find it in the intangible ‘Art’ of Medicine. In their writing they are not so much charting the loss of an art; rather, they are re-affirming its value. Late in the day, no longer bedazzled by the glare of medical science and the hurly-burly of the daily grind, they appreciate its understated constancy. They understand the precious nature of that art and its intrinsic importance, its centrality, to the practice of medicine.

It turns out that the writings of the older physician contain a message that is relevant to us all. They write to bequeath their successors this hopeful insight, that amongst so much change there are some things that endure; that a disposition to exercise the Art can sustain an entire professional life; treasure it now and not just at the end. For as night follows day, eventually the sun will set on our own careers. As we, in our turn, face up to the obsolescence of our factual knowledge and the atrophy of our practical skills, we can remain fulfilled as doctors if we celebrate the enduring nature of our experiences, our interactions with patients and with colleagues, our contributions to the human quality of medical practice and to the virtuous nature of our profession.

Steadily, the day draws to its close. A delicate fragrance of moonflowers drifts in through the study window; far off, the screech of a barn owl. The vespertine doctor sighs, gazes back above the fading tree-line of their career, and sees further and more clearly than ever.

For age is opportunity no less

Than youth itself, but in another dress,

And as the evening twilight fades away

The sky is filled with stars, invisible by day. ⁶

Gnarled fingers stroke a silvered chin. They begin to write.