AMA Journal of Ethics^®

Abstract

William Osler (1849-1919) was an academic physician who has been revered by many as an accomplished internist of his time. His contributions to the philosophy and practice of medicine foreground characteristics of a compassionate caregiver, including imperturbability and equanimity. This article defines these qualities, argues that Osler demonstrated both, and suggests how today’s clinicians can apply these qualities to their own pursuits of stillness in their practices and relationships with patients.

Introduction

Traditional medical school curricula seem to have minimal space for teaching students to deal with emotional challenges and the toil of training and subsequent practice. To soothe their anxiety, fatigue, and, at times depression, students can seek stillness through introspection and study of William Osler’s Aequanimitas.^1,2,3 Osler (1849-1919) was an iconic clinician who some have said was the greatest academic internist of his time.^4,5 Osler’s idealized caregiver, as described in Aequanimitas and commentaries by Osler’s biographers, requires an understanding of mindful practice, cultivated through insight into the humanities and a humanitarian approach to the patient and oneself.^5,6,7,8,9 Osler’s sympathy, empathy, and steadfastness while caring for patients influenced many caregivers during his lifetime and afterwards. These qualities can, and should, be linked to emotional stillness. Osler was not, however, the first clinician to champion the concepts of sympathy, empathy, and steadfastness. Others in the 18th century promoted compassionate care with principles similar to those of Osler. For example, Thomas Percival’s 1803 treatise, “Medical Ethics or a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons,” has been hailed as a “milestone in the development of modern codes of medical ethics”¹⁰—just as, I would argue, Osler’s Aequanimitas represents a milestone in medical etiquettes by including what Osler described as imperturbability and equanimity.¹⁰ Perhaps these words, ascribed to Osler, are better remembered than Percival’s precepts because of their relevance to our time, when exploding administrative demands and officious regulations consume considerable resources and can lead to burnout. We can cultivate imperturbability and equanimity to resolve emotional challenges because the stillness they generate can be therapeutic, improve health care, and provide solace for the clinician.

Evolution of Modern Medicine

Paul Starr characterized the evolution of modern American medicine in his 1983 (updated in 2017) Pulitzer and Bancroft prize-winning book, The Social Transformation of American Medicine.¹¹ We’ve steadily moved from a fee-for-service platform to myriad models, including what is now often termed value-based care and managed care. All of these changes have occurred in a heavily scrutinized and regulated milieu, with clinicians spending mind-boggling amounts of time massaging electronic medical records while attempting to achieve admirable patient satisfaction scores and outcomes. Although the practice of medicine in the late 1890s was different than today, a similarity was the centrality of the patient-clinician relationship paired with practitioner competence and caring. This type of patient care requires that the clinician have insight, empathy, and an ability to prevent, diagnose, and manage disease with imperturbability and equanimity. Establishing trust on the basis of stillness resulting from these qualities still resonates in our maddening professional world today.

Osler’s Essay

Aequanimitas was the title of Osler’s 1889 May Day address for the University of Pennsylvania medical school graduating class.¹ It was a short lecture, as the 39-year-old Osler (who would soon leave for Baltimore and Johns Hopkins University to become one of the Big Four medical school founding fathers) noted that the students were busy with celebrations.

The address was a reflection on relationships of physicians, surgeons, and perhaps health care practitioners generally with their patients. In the published essay, Osler introduced the concepts of imperturbability and equanimity with a frontispiece quotation from Marcus Aurelius: “Thou must be like a promontory of the sea, against which, though the waves beat continually, yet it both itself stands, and about it are those swelling waves stilled and quieted.”¹ Two major themes or qualities emerge in this essay. The first, imperturbability, refers to “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.”¹ Equanimity, a second theme or quality, was said to be “as important in our pilgrimage as imperturbability.”¹ Importantly, these 2 essay themes did not mean that emotional caring for the patient was absent. Also important is that the target audience of the essay wasn’t just medical students and physicians but other health care practitioners, including nurses.

Equanimity produces an emotional stillness, or peacefulness, from which empathic care emerges.

The address became the lead work in Osler’s first book of essays titled Aequanimitas With Other Addresses to Medical Students, Nurses and Practitioners of Medicine (1904, with a third edition in 1932).¹ The Eli Lily Company distributed 150 000 copies of the third edition to graduating medical students between 1932 and 1953, with others receiving the collection well into the 1970s.⁸ Charles S. Bryan, physician, academician, accomplished historian, past president of the American Osler Society, and editor of the monumental Sir William Osler: An Encyclopedia has addressed the meaning of the work as well as the controversy it generated.^2,3,6 Critics of Osler fault his endorsement of imperturbability, with its concomitant quality of equanimity,^12,13 as symptomatic of emotional detachment from the patient and thus of apathy and an absence of caring. However, Osler had defenders.^4,14,15 Bryan’s thoughtful defense, based on his assessment of Osler’s writings juxtaposed to those of Stoic philosophers, is that equanimity constitutes not apatheia (absence of emotion or apathy) or eupatheia (allowance for good emotions) but rather metriopatheia (measured emotions).⁶ Importantly, equanimity produces an emotional stillness, or peacefulness, from which empathic care emerges. Bryan also points out that critique of Osler for not using the word empathy is misguided, as the word did not enter English lexicon until 1909.⁶

E.E. Brush II, who graduated from Johns Hopkins School of Medicine in 1903 and had observed Osler’s bedside teaching, patient interactions, and relationships in general,¹⁶ also endorsed the wisdom of Osler’s philosophy and particularly what Osler called phlegm, or imperturbability. Osler noted that “the physician who has the misfortune to be without it [phlegm] … loses rapidly the confidence of his patients.”¹ This statement emphasizes the importance of stillness lying within the caregiver—despite the chaos of some patient encounters—and its centrality to trust. Brush believed that Osler was simply putting the patient at ease.¹⁶ Indeed, imperturbability facilitates calmness and stillness that cultivates effective patient-clinician relationships.

Osler’s Influence on Curricula

Osler’s ideals can be applied to medical school curricula competency development frameworks. For example, Epstein and Hundert argued for a multimethod assessment of professional competence that includes clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork in addition to the usual core knowledge and skills.¹⁷ Habits of the mind were included in the dimensions of professional competence with the goal of trainees gaining insight into their own emotions.¹⁷ In 2002, influenced by this framework, Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University (CWRU) was created.¹⁸

CWRU came to have 2 schools of medicine (CWRU School of Medicine and CCLCM), each with distinctive curricula. Both schools of medicine include a significant focus on the humanities and on personal health, well-being, and burnout. Empathic patient care is constantly stressed. Competency-based education and the humanities have been employed to foster self-reflection. Foundational thinking contained in Aequanimitas runs through the CCLCM curriculum in particular, with an emphasis on small-group, noncompetitive, problem-based learning and early exposure to patient care. In CCLCM, traditional medical school courses become threads running through case-based discussions. Humanities, professionalism, and professional identity formation are as important as traditional medical school topics, such as anatomy, physiology, and pharmacology. In order to promote teamwork rather than competition, there are no tests, grades, or academic distinctions in the CCLCM curriculum. Successful development of 9 competencies is necessary to graduate, with 3 having roots in the humanities: professionalism (students must demonstrate compassion, respect, honesty, and ethical practices), personal and professional development, and reflective practice (students must demonstrate insight into the development of the lifelong skills necessary to become a trusted health care professional). Reflective practice is the competency that addresses introspection, stillness, imperturbability, and equanimity. Development of the CCLCM curriculum is an example of how Osler’s concepts and teaching have endured for over a century.

How Equanimity and Stillness Help

Health care practitioner burnout is a devastating syndrome characterized by depersonalization and emotional exhaustion, which can lead to depression and disengagement.^19,20,21,22 It is rampant, with rates of burnout exceeding 50% in studies of residents and practicing physicians,¹⁹ and problematic, as it can result in medical errors as well as other significant consequences.²⁰ Health care practitioners wearing a carapace of invincibility may fail to recognize burnout, which is driven by excessive workloads, draconian clerical burdens, lack of control over issues affecting work lives, and inadequate organizational support. Studies have found that women and younger professionals appear more vulnerable to burnout.^19,20,22 Cultivating stillness, as reflected in the term equanimity, can help.

Stillness has meanings related to silence and motionlessness, but the term can also mean emotional calmness, serenity, tranquility, placidity, quietness, and peace. Personal introspection and self-discovery can manifest as equanimity and lead to stillness. Equanimity can, for example, ease the disquiet of emotions associated with delivering bad news or working in a hospice environment.²³ Health care professionals have shared their experiences of travail and how the stillness born of equanimity leads to redemption.^24,25 

Wear It on a Badge

A lanyard embroidered with the single word Aequanimitas holds my Cleveland Clinic identification badge. It was distributed by the American Osler Society, an academic endeavor focused on the relevance of Oslerian values in the context of the historic evolution of the health care profession.²⁶ The lanyard prompts clinicians to meditate on the patients, colleagues, other caregivers, administrators, friends, and teams required to make an academic—or any—medical center thrive while they compassionately minister to patients. Thoughts become, in a moment of stillness, grounded in personal experience and the insights Osler passed along. Those thoughts spill over to the days in clinic or hospital and even to our personal lives. It is essential to expose our students to the concepts of Osler and other great role models generally and to the power of imperturbability and equanimity specifically.