Aequanimitas Revisited

Mental calmness, composure, and evenness of temper,
especially in a difficult situation. OED.

With snow continuing to fall through the shivering Colorado sky, the brilliance of winter’s stark white cleanliness betrays a dark and somber start to this day. I have learned that a friend is dead. Sitting in front of my laptop and staring sidelong at the heavy bend of steam rising above my milky Twinings affords nothing but restlessness and discontent. Green cardamom, cinnamon, cloves, ginger, and a hint of black pepper try their best to clear my head. Their hapless task is overwhelming this morning.

My hesitant fingers point the browser to Pubmed. An uneasy but directed search brings me to this dated but chilling paper:

Schemhammer ES, Colditz GA. “Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec;161(12):2295-302.

Ultimately, this study derived 24 suicide rate ratios for male physicians and 13 for women. Long story short, their statistical analysis generated gender specific aggregate ratios compared to the general population as follows:

Male 1.41 (95% CI 1.21-1.65)

Female 2.27 (95% CI 1.90-2.73)

These are staggering data. Male physicians are nearly one-and-a-half times more likely to commit suicide, while females carry well over a two-fold risk, when compared to the lay populace. And, sadly, it is likely that many more losses remain unidentified due to continual underreporting of physician suicide. That is, the numbers are probably worse.

Furthermore, there is some, albeit scanty, evidence that physicians feel uncomfortable in turning to colleagues for help and instead resort to alcohol or drugs and isolation.

– Schemhammer and Colditz.

So, what has been done by the profession to address this problem? The well-known journey from stress, self-doubt, and fear running into depression and desolation then on to self-medication and self-harm. What has been done? Not enough. I am reminded of the ever-present and deliberate question asked at every surgery M&M conference, “What can we do better next time?” Indeed.

I am a surgeon. I love being a surgeon. I love the history. I love the tradition. I love the steely stoicism. As such, this morning has generated feelings that I try very hard to avoid. Perhaps, this is the problem.

In 1889, Osler, giving a valedictory address at the University of Pennsylvania entitled “Aequanimitas,” emphatically defines the “essential body virtue” of the physician and surgeon:

Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciatedwilliam_osler_c1912 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 is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.

But what of this physician and surgeon after the ordinary emergencies have been handled, so to speak? Wherein is the practitioner to find sanctuary to contemplate what they have seen and what they have done? Furthermore, risking disrespect to a giant, I would argue that 125 years of medical complexity has transformed what it means to tackle an ordinary emergency. Does not the gravity of our decisions reside – perturbed eternal – in our own mind’s eye? In our mirrored countenance? In our soul?

To my questions, Osler offers no answer or sympathy. He continues:

…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. It is sad to think that, for some of you, there is in store disappointment, perhaps failure.

I decline to agree. Steely stoicism has its place. Ten seconds at bedside – knife in hand – in the trauma bay will teach that lesson ruthlessly. However, those gentler influences are vital to giving the physician and surgeon a purpose. They cannot be wrenched from the heart. I fear that, should this happen unabated, the result is simple. It’s mathematical. Statistical. 1.41 and 2.27.

Rachel, your loss is a painful one. Painful for me, your friends and, sadly, for your patients as well. I wish I could have helped you. We all wish we could have rushed to your aid. We, as friends and colleagues, have failed you. I’m sorry.

My masala chai was uncharacteristically bitter this morning. There will be no Ayurvedic soothing today.

As of yesterday, late in the evening, my count of colleagues lost to suicide has risen.

Yesterday. Two.

Today.

Three…

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