Being a physician is hard. And given the current landscape of medicine, it feels as though practicing medicine may be as difficult as it ever has been as evidenced by extraordinarily high rates of stress and physician burnout.
However, in these times I often find it helpful to seek the perspective and accumulated wisdom from those who have come before us and dealt with the challenges of being a doctor in their own time and place.
William Osler is an iconic figure in internal medicine and medical education. However, he was also an astute observer of medicine and the experience of being a physician. Osler lived from 1849 to 1918, a time when medicine and the pressures physicians were forced to deal with were markedly different from what we experience today. There were no electronic health records, documentation requirements, or insurance preauthorizations, and the pace of patient care was much slower. However, there were also no antibiotics, no forms of advanced imaging, or even a basic understanding of many of the diseases and conditions that would be encountered in daily practice.
Thus, even though there may have been fewer sources of hassle that make medical practice so challenging today, physicians at the time also had much less scientific knowledge and markedly fewer tools than we have now, and much of doctoring was simply comforting patients and families through illnesses that were incompletely understood and for which little could be done. Markedly different stressors, but significant stressors nonetheless.
And although the terminology was different, Osler spoke often of the many “cares and anxieties incident to professional life” associated with being a doctor that if unaddressed “may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.” Although the phrasing is of another era, the underlying message sounds amazingly like what we today consider to be “burnout.”*
Understanding this possibility, throughout his career Osler offered his thoughts on how physicians can seek to deal with the many challenges encountered in medical practice. Perhaps his most famous essay on the subject was given as a valedictory address to the University of Pennsylvania School of Medicine in 1889 titled Aequanimitas (interestingly, I had the unique experience of graduating from the University of Pennsylvania School of Medicine in 1989, exactly 100 years after this speech was delivered). In this missive he offered advice about managing the personal challenges of being a doctor to a group of newly-minted physicians.
In this talk, he explained the concept of aequanimitas which, while sometimes misunderstood, is perhaps the most relevant to our current challenge of personal and professional well-being.
As physicians we all know that caring for patients is a profoundly emotional enterprise – it is impossible to participate in the lives (and deaths) of others on a daily basis without being affected on a deeply human and personal level. Similarly, the emotions triggered by the environment in which we practice, such as our frustration with difficult patients (or anger at the burden of documentation and administrative tasks), can also weigh heavily on us, particularly when we feel powerless to change or improve things. These are the elements of our daily lives that may eventually lead to burnout.
Osler’s notion of aequanimitas is one of a state of mind in which the full range of emotions associated with being a physician and caring for patients can (and should) be embraced and experienced, but that the power of those emotions be understood, moderated, and not allowed to overwhelm us, cloud our judgement, or negatively influence our view of patients, our profession, or our lives.
However, aequanimitas is not a mandate to remove or suppress all emotion from the patient care process, with Osler himself noting that developing a cold detachment from patients will eventually “harden the human heart.” It is also not simply the development of an attitude of “toughing out” the daily challenges of being a physician.
Rather, the concept of aequanimitas is much deeper than that. Examining the term’s Latin roots, aequus means “even” and animus means “soul or mind.” In Osler’s concept, to flourish under the pressures and stresses of being a physician, there needs to be a balance of the mind and soul leading to an internal “quietude” that enables us to navigate the vagaries of medical practice and life. Only by achieving this balance can we fully care for our patients in a compassionate and sustainable way while being able to experience the joy of practicing medicine. Or in the words of the author Judith Sedgeman:
“… as Osler suggested at the very dawn of modern medicine, that calm, balanced and compassionate underlying quality of the healing relationship originates in the mind and soul of the healer that resonates with the mind and soul of the person seeking to be healed.”
This is the essence of what we today call “physician well-being” — where caring for ourselves and achieving an internal balance of life and work is essential to being able to care for others.
We know that there is no single way to achieve this balance of mind and soul, and how to do this will differ for each of us. It is also an elusive process that requires constant attention to maintain under the fluctuating pressures and challenges of being a doctor. However, the enduring message carried through time is that we can only effectively care for others and ourselves within the context of a healthy personality.
So there is comfort in knowing that the challenges of dealing with the stress associated with medicine is not new, and that physicians of all eras have struggled with avoiding burnout and maintaining joy in practice. In seeking to achieve aequanimitas, Osler offered further wisdom that is as applicable today as it was over a century ago. He advised that as doctors we need to take care of ourselves, for “In no relationship is the physician more often derelict than in his duty to himself.”
* Visit Physician Well-being and Professional Satisfaction to see what ACP is doing to create a culture of wellness, improve practice efficiencies, enhance individual physician well-being, and reduce administrative burdens through its Physician Well-being & Professional Satisfaction initiative.
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