Keep calm and suture on—how to stay tranquil in the medical world

Dr, I refuse to vaccinate my child because my friend told me it causes autism. I know you say the research doesn’t agree, but I don’t trust scientists.

Oh, my blood pressure is still high? Yeh, I did fill out the script you gave me, but I never took it. I couldn’t be bothered, to be honest.

Doc, I think I have {insert rare disease}. I checked Google and I have all the symptoms. Can I please get a referral to {insert specialist’s name}?

If you’ve read this far, chances are you recognize that familiar feeling of irritation currently rising up through your chest. You likely also recognize the polite and well-practiced smile that begins creeping its way onto your face as you recall all the times you’ve had to keep your cool in the face of difficult patients. Being a doctor is hard! I don’t need to tell you that, though. Between seeing patients, dealing with management issues, keeping up with CME requirements, and—you know—saving lives, the medical environment can get very stressful! Add difficult situations, infuriating patients, and complex medical cases to the mix, and keeping a cool head all the time becomes a downright challenge. But the ability to stay calm is as important to the practice of medicine as the ability to perform diagnostic interventions and interpret chest x-rays.

William Osler once described aequanimitas (or coolness and presence of mind under all circumstances) as the premier quality of a good physician. This state of aequanimitas, or imperturbability, was considered by Osler to be the quality, which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he's flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.

Doctors often nurture their ability to stay calm as a natural byproduct of cultivating the emotional skill of detachment. We learn to dissect cadavers, operate risky procedures, and deal with patient deaths by removing our emotions from the equation. But Osler believed in cultivating calmness without losing our humanity. He implored physicians to cultivate such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening the human heart by which we live.

So how do we embody a state of aequanimitas without simultaneously losing touch with our humanity?

A few thousand years ago, the ancient Romans and Greeks built a powerful philosophy that has made a decided comeback in recent years. Often described as the Buddhism of the West, stoicism prescribes a way of living whereby building a life based on tranquility, personal growth, and love for humanity is sufficient for happiness.

Stoics are intensely rational and warn against allowing emotions to overtake the faculty of reason. Focusing heavily on the role that ethics plays in the development of personal meaning, stoicism recognizes that your broader world view will impact the form that your ethics takes. Modern Stoics, thus, strongly emphasize the role that science plays in informing morality and, indeed, daily life.

This is important because living an ethical life, which according to Stoic philosophers centers around achieving personal greatness and nurturing a genuine love for humanity, moves you along the path to building a life of consistent tranquility and joy. And this is where it gets interesting. Since tranquility is simply a state of emotional calmness, and every emotion has a rational component to it, it follows that achieving tranquility is an exercise in using reason to control emotion.

Sounds familiar, doesn’t it?

Read any book about happiness and you’ll come across the same idea over and over again—control your thoughts so that you can control your emotions.

Think happy, be happy. Think calm, be calm. Accept your circumstances and be proactive about resolving them, rather than mindlessly reacting to them. Stephen Covey describes this as exercising your internal locus of control in the 7 Habits of Highly Effective People. He suggests that your greatest power is your ability to choose your response to whatever situation you find yourself in. When we’re faced with particularly difficult patients (or cases) in the clinic, we find ourselves trying to beat down the rising wave of complex emotions with the rational voice in our heads telling us that these feelings need to be packed away.

This becomes a pretty exhausting habit over time. Physicians spend so much time focused on the humdrum of daily practice, reacting against the thousands of little problems that gnaw at us each and every day, that we forget to allocate time to building our emotional armor. We aim to survive rather than thrive. But what would it look like for a physician to actively nurture a state of calmness in his or her life? For a physician taking a leaf out of the Stoic book, remaining calm in the face of difficulty isn’t even a question. It just happens. They’ve already done the hard work of maintaining emotional tranquility at every other moment and the situation at hand is just another blip in the road.

Maintaining tranquility is a practice. It requires work and is entirely an exercise based on managing your emotions. These exercises are often used by Stoics to help them guard against emotional instability and maintain a calm attitude in the face of life. What would {insert superhero} do? Seneca, a famed Stoic philosopher, advised his students to seek out role models for themselves and map out a plan to becoming more like them. He suggested that without a ruler to (measure yourself against) you can’t make crooked, straight. Find your emotional superhero (could be your partner, one of your Zen colleagues, or one of our awesome teachers!) and try to channel their Zen-ness into your life.

Negative visualization

This seems counter-intuitive but it's a well-known Stoic activity and works, if managed, without intense emotions. Imagine all possible negative outcomes of a given event, but do so in a detached manner. See these outcomes in your mind’s eye but do not emotionally respond to them—become an impartial observer to your own imagination. Imagine negative outcomes so that if they do occur, they won’t take you by surprise. Accept the $2-a-day challenge. Often, the largest component of the low-level stress we become accustomed to living with comes out of a fear that we’ll lose what we have. What if we lost our job? Our house? Our income? Living a life of tranquility means accepting that the worst may happen and that you’ll still be okay. Spend time, every so often, living in a state of voluntary discomfort (Can you live on $2-a-day for a week? Sleep on the floor for a night?) to emotionally train yourself for a time when you may need to actually live that way.

Accept your fate

The Stoic philosophy is based on reason and acknowledges that not everything is within an individual’s domain of control. Though fate is often considered a religious term, in the context of Stoicism, it simply refers to that which we can’t control. Stoics add a reserve clause to every action they take (I’ll fix {insert case} if nothing prevents me) as a reminder to do everything within their power to make it happen but that, ultimately, they shouldn’t beat themselves up if it doesn’t work out. In doing so, Stoics focus on what they can control and learn to love their life as it is. Become okay with your life, your situation, and whatever else comes up day-to-day, and that sense of calm becomes much easier to maintain.

Don’t get attached

Nothing is guaranteed in life. What you have today could quite easily disappear tomorrow. Accept this fact and live with the understanding that you can enjoy things without attaching your happiness to them. Remind yourself that everything you think you own is not really yours—it can be taken away from you. Living with this reality makes it far easier to stay calm if you really were to lose them. Ultimately, tranquility is a state of mind. Staying resilient and calm in the face of adversity is much easier if you build the blocks to living that way consistently rather than trying to become calm when something bad happens.

What are your tips for staying calm as a physician? Comment below!