Aequanimaty and Imperturbability

Guest Commentary

“To prevent disease, to relieve
suffering and to heal the sick
—this is our work.”
                              –Sir William Osler

Canadian medical educator Sir William Osler (1849-1919) is, in my opinion, one of the most influential English-speaking physicians in the history of Western medicine. Following postgraduate training in England and Europe, he taught medicine and pathology at many institutions including McGill University and the University of Pennsylvania, and was the first professor of medicine at Johns Hopkins University in 1889. In 1905, Osler became Regius Professor of Medicine at Oxford. 

HIS MANY ROLES

Internist. Osler is considered the father of internal medicine and authored the widely referenced textbook, “The Principles and Practice of Medicine” in 1892. In fact, this text inspired John D. Rockefeller to establish the Rockefeller Institute for Medical Research. Note: Osler’s description of infectious endocarditis led to his name forever being associated with infectious nodules: painful, purple nodes on the palm and soles of afflicted patients are known as Osler’s nodes. 

Medical educator. Osler’s greatest legacy was his work as a medical educator. He pioneered the concept of teaching students through interaction with patients. He championed the concept of gathering knowledge at the bedside. Osler wrote, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”¹

Professor. Osler prided himself on his role as a medical professor. He was once quoted, “On my epitaph I would like nothing else written other than ‘he taught medical students in the wards,’ for I view this by far as the single greatest thing I have ever done.”² 

THE ART OF MEDICINE

It is clear that Osler greatly contributed to the science of medicine, lending more documented detail on physiology and disease process than perhaps anyone that preceded him. So, what did he have to offer with regards to the art of medicine? Osler indoctrinated two cardinal concepts to his students:

Imperturbability. Every physician should have the “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, and passiveness. The physician who has the misfortune to be without, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary circumstances, loses rapidly the confidence of patients.”¹

Imperturbability comes from wide experience and a deep understanding of the subject matter. Of this notion, Osler wrote, “No quality takes higher rank.”¹ He recognized that education, practice, and experience would help the student to develop this skill.

I can remember a young physician, only a year out of medical school, who did not showcase his imperturbability in a time of crisis. As a medical student, I observed this new physician called onto the wards to attend to a patient suffering from shock. The patient was with altered mental status, hypotension, and near cardiac arrest. The intern, who to his defense had no desire whatsoever to be a somatic physician, rushed out of the room chaotically. Obviously flustered, waving his arms frantically he shouted to the nurse, “Someone call a doctor!” To which the grounded nurse replied, “You are a doctor!” Ultimately a “code blue” was called and the patient was transferred to the coronary care unit. To this day, I am certain that the intern, now a practicing psychiatrist, is thankful that he is far away from the medical wards. 

The notion of imperturbability is also described in the aphorism, “the first pulse you should take in a code is your own.” In other words, when faced with an emergency, check yourself to be sure that you are not overreacting or flustered before looking to render aid. This is easier said than done, particularly for young healers. But do not despair over being of a young age. Osler also felt that “the real work of life is done before the 40th year and that after the 60th year it would be best for the world and best for themselves if men rested from their labours.”³ 

Aequanimaty. An important accompaniment to imperturbability is aequanimaty—defined as the mental embodiment of imperturbability. An example cited in Osler’s “Aequanimatus,” the physician’s ability to bear, with composure, the misfortune of others. For some this may come as a natural skill. For others, it must be learned. 

Being patient with those who may not have attained your level of knowledge or experience is a display of aequanimaty. Inherent in this concept is the fact that absolute truth is unattainable and that we must be content in our knowledge that in so many situations in medicine—and in life—we do not hold all the pieces of the puzzle.

CLINICAL APPLICATIONS

Osler made many contributions to clinical medicine, including helping to create the system of residency training that is still used today. In “Teacher and Student,” Osler lists several characteristics that each student should strive toward.⁴ 

First, perfect the “art of detachment,” or be mindful to properly balance work and play. This is not to suggest that students should not enjoy themselves. Instead, we should show self-control in pursuing our delights and not allow ourselves to be overly attached to certain frivolous attractions. Osler urges that we develop a discipline of self-control so that we may live laborious days.

Second, understand the “Virtue of Method.” Osler cites the efficiency of the successful businessman, who owes part of his success to the fact that he has developed a systematic and an orderly arrangement to his work. The best medical students and physicians I have worked with have figured this out. Some carry a notebook with them to keep track of ideas, others keep a log of outstanding tests they have ordered and are awaiting the results. We healers must practice medicine under the guidelines of an established system and method. In other words, get into the habit of doing the same thing every time so certain behaviors become your usual and customary practice. 

A great healer, at a minimum, should also be competent. As a third quality, with competence exude the “grace of humility”—recognition that we are capable of personal error and cannot always be right and moreover, at some point we are simply going to be wrong. With every occupation come risks and consequences. If we are wrong as bakers, we may burn our rolls. But as healers, our mistakes carry a significant chance that great harm may come to our patients. An anonymous quote explains the serious truth that often, “Lawyers hang their mistakes. Journalists put their mistakes on the front page. Doctors bury their mistakes.” Patients will die because of our mistakes, some of which may be preventable. 

It is our goal as healers to uphold the positive qualities explained by those before us to minimize this occurrence and to learn from any misfortune so as to prevent its reoccurrence. Osler gives advice on this as well: “Errors in judgment must occur in the practice of an art which consists largely of balancing probabilities. Start, I say, with this attitude in mind, and mistakes will be acknowledged and regretted; but instead of a slow process of self-deception, with ever increasing inability to recognize truth, you will draw from your errors the very lessons, which may enable you to avoid their repetition.”⁴ 

This column is adapted from “Advice to the Healer: On the Art of Caring,” by Dr Colgan⁵. For more information, visit www.advicetotheyoungphysician.com.

References

1.Valedictory address to the University of Pennsylvania, 1989. In Aequanimatus. 3rd ed. New York: McGraw-Hill Inc., 1939.

2. Osler Library Newsletter, no. 108, 2007. Osler Library of the History of Medicine, McGill University. Available at http://www.mcgill.ca/files/osler-library/No1082007.pdf. 

3. “Preface to the Second Edition: Oxford July 1906.” In Aequanimatus. 3rd ed. New York: McGraw-Hill, Inc., 1939.

4. “Teacher and Student.” Valedictory address to the University of Minnesota, 1892. In Aequanimatus. 3rd ed. New York: McGraw-Hill, Inc., 1939;23-41.

5. Colgan R. Advice to the Healer: On the Art of Caring. 2nd ed. New York: Springer, 2012.