The Pearls for Achieving a State of Aequanimitas

| 9 September 2014

I was recently part of a group of faculty members asked to talk to the 4^th year Medical Students at Queen’s University as part of a Pearls of Practice Session focused on imparting wisdom about how to be a resilient physician and avoid burnout. Dr. Tony Sanfilippo and Dr. Reneé Fitzpatrick instructed us to provide 3 brief Pearls revealing (in 3 minutes or less), “How we have managed to remain positive and committed to our careers despite heavy workloads, competing demands and all the stresses of your busy lives.”

Dr. Tony Sanfilippo, Associate Dean, Undergraduate Medicine and Dr. Reneé Fitzpatrick , Director of Student Affairs

Tony and Renée are friends and I know that they are all too aware that many senior physicians are more bereft of balance than the new and improved model of MD. As a Head of Medicine, Cardiologist, and Principle Investigator of a research lab their kind request triggered several thoughts: Was my selection meant to be ironic? How long would my wife laugh when she hears that I have been asked to speak on the subject of work-life balance? and finally, What would I say?

The first time I thought about career-life balance was when, as a first year medical student at Queen’s, I was inculcated into the culture of William Osler. I recall we were introduced to his essay, AEQUANIMITAS, which purportedly told students and practitioners about how to achieve inner balance while the world swirled around them.

Of course, in those days my biggest goals were to perfect a competent fundoscopic exam, pass biochemistry and develop some rudimentary social skills (note to self-two of three accomplished). Aequanimitas, was something I took relatively little time to consider. The word has Latin roots: aequus meaning “even” and animus, meaning “soul or mind”. To illustrate Aequanimitas Osler opened his lecture (of the same name) with a quote from Marcus Aurelius, Emperor of Rome from 161-180 AD, who in his book Meditations advised: 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.

Thus, aequanimitas is a state of mind, reflecting balance of the mind and soul. You are calm and you calm those around you (even for Marcus that must have reflected a good day). The physician ideally sees and understands the pain of a patient, displays empathy but is able to handle all this without having their mind disturbed. Judith Sedgeman said it nicely, “And, 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. Until and unless the healer knows that state, only one side of the coin is visible.” Judith A. Sedgeman, EdD Perhaps my pearls for the medical students should relate to instructing them how I have learned to nurture my inner Osler? Aequanimitas sounds good in theory, but how in practice do any of us achieve and sustain this balanced state? My colleague and co-presenter in the Pearls session, Dr. Mike O’Reilly noted that balance in ones life was achievable but temporally constrained, like standing atop an exercise ball. You can stand atop the ball and keep it immobile for a while; but even if you’re well balanced, you will not remain atop your perch indefinitely and constant re-equilibration is required. Aequanimitas is an ideal that is neither easily taught or frequently on display. As I listened to my colleagues present their Pearls, advice on how to survive and thrive in Medicine, many of their points resonated and I thought I might pass these Pearls on to you. Some were brief (get adequate sleep), others used acronyms (nurture your FORCE), and others were case-based, reflecting wisdom acquired from years in the trenches. We presented to the 4^th year medical school class in alphabetical order…so I was up first. My contribution was to remind the students that this profession is endlessly challenging and can satisfy one for a lifetime (i.e. they have chosen your career wisely). However, while it is a privilege to be a physician, the work can periodically overwhelm even the strongest person. In my 33 years in the doctor game I confess that there are times when I feel stressed, pressured, over-tired and irritable (or as the kids call it, burned out). In fact, I will admit as I write this at 10pm, tonight is one of those nights! That said, I know that I can deal with these feelings and that with a bit of sleep, exercise or conversation with a friend, the deviation in my gyroscope will correct and I will resume my course. My Pearls: Pearl 1: Stress is part of living: Accept that you and every other physician feel stress. Recognize that, for most of us, balance involves oscillation around a mean. Some days we are a little high, some days a little low. With self-examination one can minimize these oscillations and be somewhat like Marcus Aurelius-a source of calm for ourselves and those around us. Whether you call it stress or burn out, whether precipitated by a poor patient outcome, too little sleep, too many grants to write or conflict with a colleague, the feelings can be managed and you can learn to minimize the frequency and intensity of the stress. In many regards the stress is reduced as you move from medical school to residency. Medical school is like the ride up a roller coaster…quiet with a great view of the action…and then the anxiety of what is to come gives way to the sudden plunge. Residency is more like flying…you are moving fast and there are some risks but now you are the pilot (or at least the co-pilot) …more responsibility but more control. You finally get to spread your wings and fly. This relieves stress. Pearl 2: Lessons from parenting: Becoming a physician is like becoming a parent. One day you are single, responsible only for yourself. Then you are married or have a partner...still not too bad. You are still pursuing your personal life interests and are relatively unrestrained. Then you become a parent. You abandon your position at the centre of the universe and now you orbit a being that will be your endless project, your source of pleasure and pain. Like Medicine, a child will enrich you but will also provide you with days when you feel inadequate and imbalanced. Interestingly the Pearls for thriving as a physician or a new parent are similar:

Exercise. A healthy body is essential to maintaining a healthy mind. I play old guy hockey (and bore people endlessly with accounts that are only loosely rooted in reality).
Talk to your colleagues and share the ups and downs. It is often when you feel least like talking you most need to share your thoughts.
Share your career experiences with your partner, downs as well as ups. This is not only to help yourself. It is selfish and can be a source of separation if you carry your troubles alone.
Read literature. Only through literature can you experience the full scope of the human experience. Life is too short to acquire this otherwise. It is gratifying to read the thoughts that you felt were yours alone, as expressed by a masterful author.
Embrace music. Ideally play some instrument or sing-if not make listening to music a part of your life. For me it is playing guitar that brings tranquility.

Pearl 3: Perspective: When considering one’s problems as a medical student or physician, remember the challenges of people who work for minimum wage with little or no job security or societal respect. We live in a privileged country and hold a privileged position….our problems would be a fond dream for many people.

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Dr. Jennifer Carpenter:

Assistant Professor Emergency Medicine

Jenn is an Emergency physician, educator and global health practitioner who has long worked to improve learner wellness in our Medical School. Her message was that the Canadian Medical system is imperfect (like all systems). This imperfection can stress medical students when they can’t deliver the level of care to which they aspire. But in an imperfect world learning to strive for excellence (not perfection) can allow you to deliver great care and sustain your enthusiasm. Pearl 1: Learn from your mistakes and those of others. Some of the best lessons you will learn as a physician derive from seeing a colleague do something and realizing: I never want to act that way. Negative role modeling is not as enjoyable as positive role modeling but it certainly sticks in ones’ mind. Pearl 2: Remember that the “severity” of a situation is completely dependant on the person experiencing it. Dr. Carpenter spends time looking after patients in Tanzania and realized she had to remind herself that disease severity is sometimes as much about patient perception of their disease as the dispassionate assessment of the MD. How does one deal with the fact that a splinter in the foot might bring a patient to an ER in Kingston and engender complaints about the wait while a life threatening trauma in Tanzania might be handled in a primitive ER with much less fuss? It seems Dr. Carpenter’s aplomb is aided by realizing that “Man is a giddy thing”. As a physician it is our role to help; not to judge. Pearl 3: People are much less likely to complain about physicians that have listened to them and are honest. This is great advice and both increases the odds that your patients will like you (a great source of satisfaction) and also reduce the risk of litigation. Pearl 4: Learn to accept that there are dreary and disappointing aspects to every job. The great news is that you picked a career that provides the huge opportunity for reward which more than compensates for any transient drudgery.This was one Pearl that all panellists agreed with. For all its flaws and stressors, Medicine is a desirable career (thus the 4000 applicants for the 100 seats in our medical school).

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Dr. Mala Joneja

Interim Chair of Rheumatology and Deputy Director of the Internal Medicine training program

Pearl: Mala had the best acronym for achieving aequanimitas: FORCE (Keep looking Forward, Spend time with Others, build your Resilience, remember Compassion, aim for Excellence.) Forward: Learn from the past but don’t become discouraged by prior errors and mistakes. Always look forward at how you and your practice will improve. Others: Develop friends both within and outside the profession. These “others” help keep you balanced and sane. Resilience: Do not let the rough and tumble of Medicine wear you down. By looking forward and leaning on others you can develop a resilience which lets you survive the dents and bruises that accompany a life in Medicine Compassion: Do not wall yourself off from the patient. Look into their eyes, truly see them, put yourself or a family member in their position and behave accordingly. Compassion and caring is what brought you to the profession. Excellence: Aspire to excellence-it will benefit your patients and will also benefit you personally. So, like Dr Joneja herself...be a FORCE and remember: no MD has the aequanimitas of Yoda!

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Dr. Heather Murray:

Heather is an Associate Professor of Emergency Medicine and an esteemed educator.

Pearl: Her message was simple: “The biggest threat to resilience is the stigma of error in our culture where perfection is expected. The antidote is kindness - to our patients, to ourselves and to our colleagues in the aftermath of an error.” To paraphrase Dr. Murray, Don’t elevate yourself by putting others down! The corollary of this advice was to encourage us to be kind to each other. Her comments reminded me of this quote from Ian MacLaren, “Let us be kind to one another, for most of us are fighting a hard battle.” MacLaren was the pseudonym for Rev. John Watson, a Scottish author who died in 1907.

(Jack Handey-SNL, Deep Thoughts)

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Dr. Michael O’Reilly

Assistant Professor in the Division of Cardiology

Mike was the only practitioner who had spent the majority of his career in private practice, working as a cardiologist in Nova Scotia. Pearl 1: Excessive work has destructive effects on ones personal health. Engage in regular exercise, like running, for its physical and mental benefits.

Pearl 2: Spend time with your spouse/partner Pearl 3: Schedule blocks of 24 hours of uninterrupted non-medical activity into your life...that's right, create an entire lunar day with no medical intrusion. Pearl 4: Strive for excellence (not perfection). Excellence is achievable, perfection ….not so much.

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Dr. David Taylor:

Assistant Professor in the Division of General Internal Medicine

As a veteran of 20 weeks/year on the in-patient service he had the smallest pearl but this pearl had substantial luster.

Pearl: Get adequate sleep! The lack of sleep is without question a solvent that can dissolve ones’ Aequanimitas. David advocated shooting for 8 hours a night whenever possible and noted the ability for clerks and others to cope with life and death (and the tedium of being on call) was greatly enhanced by turning off the television and heading to slumberland. Of course, sleep is not always easy to come by, as illustrated in this cartoon from the New Yorker.

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Dr. David Walker:

Professor in the Department of Emergency Medicine and former Dean of the Faculty of Health Sciences at Queen’s

Dr. Walker used a case to illustrate the fact that Medicine can at times make you want to cry (and then told us that this response is OK). His challenging case involved the perfect storm of working through the pain of a missed diagnosis while balancing an unrelated but simultaneous life stressor (which spouse looks after the sick child when both are to be at work!....a challenge to Aequanimitas that most of us will or have faced).

Pearl 1: Allow yourself to be human. You should not achieve resilience by denying the pain and frustrations of patient care. If you can laugh with a patient you ought to be able to cry with a patient when the circumstance dictates. Don’t become hardened and unfeeling, distanced emotionally, using booze and pills to become numb to human suffering. Pearl 2: Share your burden with your partner and with friends and keep your career in perspective-we physicians are not as special as we think we are. Pearl 3: Always take a phone call from your spouse, partner or kids-there is time for this (even though you may feel there is not). Pearl 4: Cultivate friends out side the medical profession (their perspective provides grounding). Pearl 5: Laugh with your patients and don’t take yourself too seriously. You are not that special. Pearl 6: Keep fit. Play golf and run. Get a hobby. Dr. Walker advocated nonmedical hobbies-such as pursuing small white balls through fields and streams! Perhaps David recognizes that golf shifts our focus to the future… as Ben Hogan said…

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Dr. Jim Wilson:

Dr. Jim Wilson is a former head of Urology and is known for his brevity and clarity. He is seen in the centre of this image with Drs Ross Walker and Ron Wigle, receiving the 2014 Ron Wigle Mentorship Award. Jim did not disappoint. He was the final presenter and summarized the prior speakers - reinforcing the one Pearl shared by all speakers… Medicine is a great and challenging adventure full of highs and lows, both of which can be managed. Pearl 1: Enjoy your patients – Get to know them as people, learn about their lives. This is most feasible when you have longitudinal care responsibilities. This personal attention enriches you and is appreciated by the patients. Pearl 2: Reinvent your self at least every 10 years: Tackle a new challenge or change careers within Medicine altogether. So in conclusion, when you feel stressed or burnt out, remember this is normal. Hopefully the Pearls we have offered will help you through medical school and beyond. The session made me consider the term Pearl in another sense. The creation of even the most precious pearl after all is stimulated by irritants that annoy an oyster. The periodic frustrations, irritations and imperfections that you will experience over your career will lead you to create the Pearl that is your Career in Medicine.