John Donne A nocturnall on St Lucies day, Being the shortest day
Soon it will be the ‘yeares midnight’ again. For our ancestors this was a time of mystery and fear as the days got darker and darker and the sun sank lower in the sky. They worried that it would eventually disappear and leave them in permanent darkness and cold. Many of the traditions and symbols of this time of year, like the holly and the ivy, mistletoe, and the Christmas tree, are remnants of pagan rituals to appease the gods and persuade them to return light and warmth to the earth. Of course we now know that there is a simple scientific reason for the seasons. The earth tilts slightly on its axis like a spinning top fixed in an off-balance position so that during the winter the sun's rays hit the Earth at a shallow angle, and days are short. On the shortest day the sun's angle starts to get higher again, and the days get longer. This shift follows predictable mathematical laws and astronomers can work out the exact time it will happen each year — sometime between 21 and 22 December.
But the dark can still have a deep effect on us. When I was a trainee I worked out-of-hours in a rudimentary co-op. It was before the days of triage, primary care centres, and drivers, and most of the contacts were home visits. I would spend the whole shift haring around in a state of panic trying not to let it slip into a state of utter blind panic. Occasionally I had to dash high up the Afan valley to the remote village of Pontrhydyfen, and as I stumbled around trying to find my next call I often remembered an interview I heard with the village's most famous son. Richard Burton was being asked about his religious beliefs: ‘I'm an atheist’, he replied confidently before pausing for effect and adding, in that rich, gravelly voice, sounding like a mixture of cigarettes and honey, ‘apart from when it's dark’. Perhaps I imagined it, but he seemed to roll the word dark around with relish as if he was somehow pleased that his daytime rationalism was counterbalanced by something more mysterious.
I was new to general practice, still paddling in the shallows of coping with uncertainty, and his words struck a chord. I had as much factual medical knowledge then as I have now, if not more, but it didn't seem to apply to a lot of what I had to deal with on these frantic shifts. The problems and symptoms often didn't come in neat categories with clear diagnoses fitting in with simple protocols and management plans. I learned that medicine done in the dark was often different to the certainties of rational scientific medicine.
Years on, I believe in evidence-based medicine, and the great benefits to patients of the enormous growth in scientific understanding of disease — but not when it's dark. The dark of unpredictability and uncertainty that still exists, despite all of our increasing knowledge; the part of being a doctor that deals with people and illnesses; and the anxieties (both the patients' and ours), that go hand in hand, not just mechanistic disease processes. This darkness can't always be dispelled by extra learning, by developing more guidelines or more training, but it often helps nurture the flexibility and pragmatism that is essential to general practice.
At 12.40 GMT on the 21 December the Earth's tilt will, again, cause the sun to start climbing the sky, and we will start the slow return to the light and warmth of summer. At the end of this year general practice is also going to finally tilt on its axis away from the dark. I won't miss the fatigue, the disruption to normal life, the lack of sleep, and the occasional frustrating trivialities masquerading as emergencies. But what will happen to the counterbalance that it brings, the perspective and balance that can help keep us fully rounded doctors as opposed to medical scientists?
- © British Journal of General Practice, 2004.
