In search of aequanimitas

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.

— Marcus Aurelius, as quoted by Osler in Aequanimitas and Other Addresses, 2nd ed., 1906

Sir William Osler is a figure for whom I have an ambivalent affection. I have come to view him as one might an elderly male relative, an uncle perhaps, who possesses both great acumen and an embarrassing tendency to make statements that betray his old-fashioned prejudices. He gets dragged out at family occasions to give speeches that are duly applauded, and because everyone admires him so much they are willing to overlook his little foibles.

I‚m no expert on Osler, nor am I one of those fanatics who join societies to ponder his words of wisdom. But, like most Canadian physicians, I have encountered him from time to time over the span of my career, like a particularly persistent patient who keeps popping up in the emergency room, demanding to be seen.

I first made my acquaintance with Dr. Osler in medical school, when I was given a collection of his writings, Aequanimitas and Other Addresses. ”Many young men,” he says in the preface, ”… have written that the addresses have been helpful in forming their life ideals.” Whenever I didn‚t feel like studying, I would read one of Uncle Will‚s essays — in retrospect, a more productive use of my time than memorizing the tributaries of the superior mesenteric artery.

Osler had none of our modern scepticism about Duty, Honour and Virtue. In his stilted Victorian manner, he preached ”loyalty to the best interests of the noblest of callings, and a profound belief in the gospel of the day‚s work.” Wagging his finger, he reminded me again and again of the high purpose to which I was committed.

I was particularly struck by the valedictory address given in 1889 at the University of Pennsylvania. In it, Osler spoke of ”aequanimitas,” describing an ”imperturbability … indissolubly associated with wide experience and an intimate knowledge of the varied aspects of disease.” With aequanimitas, ”no eventuality can disturb the mental equilibrium of the physician; the possibilities are always manifest, and the course of action clear.” Gotta get me some of that, I thought.

At that time, during my preclinical years, it was hard to imagine I would ever be able to do the things expected of physicians, much less with serenity and confidence. Aequanimitas, as I understood it, represented an acceptance of whatever might result from a particular action, without the burden of anxious rumination and indecision. An attractive notion, to think of attaining such a state. But I also had a suspicion that Osler might have considered me one of those students ”who, owing to congenital defects, may never be able to acquire it.” I was, after all, female, and all of his writings (with the exception of those intended for nurses) seemed only to address young men. Uncle Will, for all his encouraging words, might be less wildly supportive were we to meet face to face.

At times I wondered if I could ever live up to Osler‚s standards. My only consolation was that he would have considered my classmates to be equally poor specimens. Perhaps the medical students of the past were made of sterner stuff. Certainly, they must have had a better classical education to understand the obscure literary allusions that embellish his addresses. I remember my first night on call as a clinical clerk. If Uncle Will had been there, I would have received a firm scolding as I hid in the call room. ”The first essential is to have your nerves well in hand,” I could hear him saying. ”Even with disaster ahead and ruin imminent, it is better to face them with a smile, and with the head erect, than to crouch at their approach.”

Osler could be annoyingly condescending toward patients at times, but he also spoke of ”the need of an infinite patience and of an ever-tender charity toward these fellow-creatures.” He reminded me of ”the likeness of their weaknesses to our own,” something I tried to remember when I started my psychiatry residency and encountered so many patients, especially those who were anxious and depressed, who needed a bit of aequanimitas themselves.

Through the intervening years, I came across Osler‚s name in many contexts — in history of medicine lectures, reference books, the name of a hospital. Osler quotations prefaced articles like verses from scripture. It was akin to seeing the name of a colleague in print: Hey, I know him. I felt a bit of pride, a bit of resentment.

And somehow, so gradually that I hardly noticed it, I cultivated a degree of aequanimitas. Perhaps I should not have been surprised; after all, Osler said that ”with practice and experience the majority of you may expect to attain [it] to a fair measure.”

But sometimes I think Osler‚s notion of aequanimitas is flawed. Surely nothing short of pathological denial can give rise to the peacefully enlightened state he attributes to Antoninus Pius as he lay dying: ”about to pass flammantia moenia mundi (the flaming rampart of the world)” with ”the watchword, Aequanimitas” on his lips.

Still, I want to believe. Because there are days — when patients‚ conditions are deteriorating, family members are lining up to see me, computer printers are jamming — when it helps me to imagine myself rising above the troubled waters of the hospital ”like a promontory of the sea.” All about me, the swelling waves are stilled and quieted, and there I stand, with Uncle Will at my side, my hand outstretched in a benediction, my face glowing in a state of perfect aequanimitas.