Can providers compartmentalize too much?
By Jacob Kaiserman
Aequanimitas! cried Doctor Osler
If you look closely at the shield of the Johns Hopkins Department of Medicine, you’ll notice the word “Aequanimitas.” Coined by Dr. William Osler, the original physician-in-chief of Johns Hopkins Hospital and a legendary medical humanist, the word closely means “imperturbability.” Osler considered this aequanimitas, a calmness amidst storm, to be the defining virtue in successful physicians. He delivered his brief essay, Aequanimitas, as a valedictorian address in 1889. And over one-hundred-and-thirty years later, healthcare providers still find meaning in his words. The essay speaks to what many modern medical practitioners call “compartmentalization” but as a second-year undergraduate, I’ve found Osler’s advice on the subject to be somewhat lacking.
Readers of the text are left with little doubt that a physician’s aequanimitas is important. Osler suggests it might be uncomfortable to see your physician betray their indecision, worry, or fear. I don’t think this is entirely true. From what I’ve learned, clinical practice does entail moments when sharing indecision, worry, and fear with a patient might be necessary and may deepen the doctor-patient relationship. Nevertheless, let’s engage with Osler’s perspective. He leaves one crucial question unanswered: exactly how do young physicians develop aequanimitas? If you were to ask Osler, he might point to spending as much time in the hospital as possible (his later essay, “The Hospital as a College,” wholly reveals that conviction). That answer, though, still dodges the other half of my question: exactly what happens in the wards, among patients, to help young physicians develop aequanimitas?
Healthcare providers find themselves pressed up against the fragile barrier between life and death, and bear witness to the most vulnerable moments of a patient’s life. Does the first journey to that precipice, and the first peek over its edge, not terrify all training practitioners? It certainly frightens me. I think Osler’s hypothetical answer offers some truth. I do wonder if a physician can only remain calm amid the storm if they’ve been in the storm before. Still, hidden behind the faculty members that Osler points to during his essay as examples of a fully matured aequanimitas, there has to be a difficult period of growth that he fails to mention.
The quote from Osler’s original lecture appears to dismiss the challenge of acquiring aequanimitas. He sometimes admonishes his audience of training physicians (who were all male) with almost impossibly simple directives. Consider this great piece of non-advice:
"Cultivate then, gentlemen, 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 all live."
It’s obvious that the medical jargon we hear in our clinics and hospitals isn’t anything new. Here, Osler encourages his students to find some balance, some critical distance, that allows them to practice effectively, but remain malleable, impressionable, human. But ask yourself: precisely when does the degree of “obtuseness” that helps providers meet the demands of medical practice become too cold, or too distant? I think that knowing where that line lies is more important than knowing that it exists. But Osler doesn’t answer — perhaps because he doesn’t know. I don’t know if anyone does.
This balancing act concerns me, as I think every healthcare provider seeks to develop aequanimitas. Can providers compartmentalize too much? We might rephrase this question in Osler-ian vocabulary: when does aequanimitas become detachment? And how can students of medicine develop their aequanimitas without becoming detached?
As you read the pieces that follow, I hope you’ll come to appreciate how difficult it can be to foster your own aequanimitas.
The minimum number was 100,000 lives and I think we’ll be substantially under that number.
I can’t look at the data anymore.
That inverted lightning bolt
tracking deaths and time
shoots up towards Heaven,
challenging God and Gauss.
For an art steeped in its humanitarianism,
medicine still clings to
like moths lured
into a lamp’s glowing embrace.
Kaplan-Meier curves? R0? Fatality rates?
Statistics gives no respite
to the sick patient’s dread.
When you dance on top of the autopsy tables
to celebrate the morgue’s empty stomach
you ignore its insatiable hunger
and forget the endless feast.
There I found that every heart is different. Some are fat, some are lean. Some are thick, some are thin. Some are fast, some are slow. Most that I worked with were desperately sick. Twelve thousand of them, all causing misery. Crushing chest pain, interminable fatigue, terrifying breathlessness.
18 June, 2016: I’ve known you from my aunt’s faded textbook. I pored over its thin pages, scrawled my pen over the stained text, and memorized all of your traits. 180/120. Poor exercise. High stress. I begged my aunt for her old blood pressure cuff so I could measure my own heart’s cyclic churning, and I locked all I knew about you away, hoping to come across you on some unexpected day and be able to hear your distinctive shout.
12 October, 2019: I’ve known you for no more than five minutes. I’m just here to check your vitals and record your contact information, but I want to know more about Peru. You laugh when I tell you I’m no physician yet because your twelve-year-old son wants to become a doctor, too. I hold the grainy photo of him that you carry in your breast pocket and notice your jaunty-toothed but prideful grin when I say that I like his olive jacket, the one you gave him. I love hearing about Martin Luther; I’m sorry that my rusty Spanish doesn’t gift me the words for the discussion of theology you had hoped to have. I see how you glance at the cuff as I wrap it around your tanned arm. You break the silence with a nervous joke about how you espera que se funciona — hope it “works.” Good word choice. Funcionar, to function. It’s all vaguely mechanical.
I listen with my aunt’s old cuff and hear you, that other you, the one I knew long ago and since stored away, shouting. 180/120. Poor exercise. High stress. I fit it all together and excitement runs through my veins. I’ve finally caught you. The insidious you, the faulty pump whose name I know and who I’ve so anxiously anticipated meeting.
My accomplishment melts into gnawing guilt when I realize that what I’ve found will kill you—you said you haven’t seen a doctor for years, how could you possibly afford it now?—and I stare into your faded eyes, falling faintly into their leather sockets, and try to tell you what I heard.