Achieving Osler’s Ideal of Imperturbability
In 2018, as Chief of Staff at our medical center, I met with a half a dozen physicians who lost their cool in the hospital in substantial ways. Some became angry with the OR staff, a few with the floor nurses, others with administrators. To a person, each of the doctors had legitimate complaints: inadequate equipment, insufficient attention to detail, or shortcomings in operations or planning. These clinicians are skilled and recognized for their patient care. What was striking in each instance was the asymmetry between how these physicians comport themselves with clinical crises as compared to non-clinical. These same master clinicians that, with equipoise and compassion, could handle life-threatening surgical bleeding, potentially lethal heart rhythms, dying patients, or demanding families would outwardly erupt or internally seethe when faced with the seemingly lesser challenge of imperfect hospital operations. Some of these physicians faced immediate consequences as a result of their actions, including the possibility of suspension form the medical staff. Others I met with were not facing serious repercussions from the hospital but were clearly suffering from their own internal frustrations; so much so in several cases that they were now in danger of being viewed as cranks or malcontents. Their ability to exert influence in the hospital or participate in projects with their peers was significantly hampered, and administrators no longer turned to them for guidance or input.
Sir William Osler delivered his famous Aequanimitas address in 1889 wherein he stated “In the physician or surgeon, no quality takes rank with imperturbability.”1 He implored the graduates to have “coolness of mind under all circumstances” (italics added for emphasis). Aequanimitas is the term physician’s use for imperturbability in the culture of medicine, but the value of imperturbability is well known in ancient wisdom, and extends across most cultures.2 Epictetus, the Greek stoic philosopher in the first century A.D., summarized the concept: “It is not occurrences that bother us, but rather our reaction to them.” The Buddha put more emphasis on our minds as being the source of our own strife when he said “Nothing can harm you as much as your own thoughts unguarded.” Regardless of our faith or background, it is cross-cultural wisdom that a person cannot find peace until he learns to conquer his thoughts.
Physicians in 2019 are not a happy group. The statistics from the Medscape National Physician Burnout, Depression & Suicide Report 2019 are sobering: 59% of the physicians surveyed were burned out or depressed.3 The top 3 coping strategies were exercise, talking with family/friends, and self-isolation. Approximately 30% turned to alcohol or drugs. Contemplation, meditation, or prayer didn’t break 10%, despite the fact that these low-cost disciplines are stressed in ancient wisdom as an effective tool for developing imperturbability. These techniques entered my life late (early 40s) after experiencing a crisis in the form of a divorce. While my career flourished, my life at home careened seemingly out of control, and it wasn’t until I began studying age-old teachings of philosophers and religious leaders that I came to recognize my deficiencies: I was reactionary, quick to blame, egocentric, and lacking in the mental resilience needed to lead myself and others. And I was in danger of joining the 59% who are burned out or depressed, despite having the career I’d hoped for. Our modern, and increasingly narrowly focused, education prepares us to tackle all manner of patients’ diseases, but at the expense of cutting our forefathers wisdom from the curriculum, and thus leaving us ill-prepared for our mind’s responses to hardship. It is sad to note that many in our profession experience significant strife as a result of the lack of focus placed on strengthening our mental resilience. I found my path by studying Buddhism, Christianity, Hinduism, Stoicism, and Taoism—but most of the world’s religions have similar basic messages and advice for living well: be selfless, be wary of your thoughts, love altruistically, and treat others as you would be treated.
A 2019 report from the Massachusetts Medical Society states that advocating for a physician “self-care … approach inaccurately suggests that the experience and consequences of burnout are the responsibility of the individual physicians.”4 While institutional factors have made the work environment increasingly challenging for physicians, we ultimately are responsible for how we respond. The most appropriate response to a difficult work environment is similar to a difficult clinical case: gather information, diagnose the problem(s), and develop solutions/treatments. Treating ourselves as hapless victims to an unfair industry will do nothing to prepare us for the new challenges we’ll face from the increasing encroachment of technological and financial demands. Better for us to emphasize now the paths to aequanimitas, both for our current challenges at hospital and home, but also for the unknowns before us. We disempower ourselves when we adopt a victimhood culture.
Several of the doctors who erupted in the hospital cited home or personal pressures as the primary source for their behavior in the hospital. This point drives home Osler’s understated message to be imperturbable in every situation, regardless of the setting. I think many of us, on first read, interpret Osler to have said that we should “have coolness of mind under all clinical circumstances,” but what we do or think outside of patient care is our business. We of course intellectually realize that we are not a unique identity at the hospital and another at home. Until we begin to practice the path to aequanimitas in the entirety of our lives, we are doomed to view ourselves as split, separate, and somehow cut off from the very people in the hospital we depend on to help us care for our patients.
“If a man is crossing a river And an empty boat collides with his own skiff, Even though he be a bad-tempered man He will not become very angry. But if he sees a man in the boat, He will shout at him to steer clear. If the shout is not heard, he will shout again, And yet again, and begin cursing. And all because there is somebody in the boat. Yet if the boat were empty. He would not be shouting, and not angry.”
The last physician I counseled came with a list of grievances and shortcomings on the hospital’s part. He wasn’t wrong, and I committed to helping change things as I could. But still I implored him to find a better way to behave than by cursing and invective. “I’d have to be a saint to not get angry!” Perhaps. And why shouldn’t Saintly be the goal? When placing a pacemaker or performing an ablation, I strive for perfection. I know that I won’t reach the goal of zero complications but nevertheless, that is my aim; as it is with all thoughtful proceduralists. We can similarly strive for zero anger. And not only for the benefit of others, but mostly for ourselves. Turning to contemplation, meditation, or prayer strikes many as soft and less than worthy tasks as they are non-scientific and not evidence-based. Indeed, a review of prayer and healing warned: “For a multitude of reasons, research on the healing effects of prayer is riddled with assumptions, challenges and contradictions that make the subject a scientific and religious minefield. We believe that the research has led nowhere, and that future research, if any, will forever be constrained.”5 Nevertheless, the absence of evidence does not imply the absence of benefit, and testimonials throughout time (humbly including myself), speak to the power of pursuing meditation and prayer for arming ourselves against angry and destructive thoughts. St Thomas A Kempis warns “Who hath a harder battle to fight than he who striveth for self-mastery?” However, physicians are accustomed to meeting the toughest of challenges. Meeting the challenge of self-mastery is critical to the profession, and will make us happier (along with everyone around us) and better physicians.
- 1.Aequanimitas. http://medicalarchives.jhmi.edu:8443/osler/aequessay.htm
- 2.Huxley, A. (1944). The Perennial Philosophy. New York, NY: HarperCollins PublishersGoogle Scholar
- 3.Medscape National Physician Burnout, Depression & Suicide Report 2019. http://medscape.com. Accessed 5 May 2019
- 4.Jha A., Illiff A. A Crisis in Health Care: A Call to Action on Physician Burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/A-Crisis-in-Health-Care%2D%2DA-Call-to-Action-on%2D%2DPhysician-Burnout/. Accessed January 2019