Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Imperturbability, Aequanimitas, and “In Shock”


Moving towards a deeper understanding of Osler's dicta of imperturbability and aequanimitas.

In Shock

I just read Dr. Rana Awdish’s excellent book, In Shock, in which she describes her own experience with a catastrophic illness—rupture of an hepatic adenoma that led to massive bleeding, hemorrhagic shock, and a near death experience. She writes beautifully about her experience, what she learned from it, and particularly what we as physicians should learn about the importance of empathizing with our patients.

As her illness unfolds over a number of years the reader is kept continually on the edge of his/her seat waiting for the next crisis to erupt and yet able to stay present because we have the reassurance that somehow Dr. Awdish made it through to write this book—a reassurance that we don’t have with our patients.

And it is perhaps that fear of what may happen, including the possible death of our patients, which leads many of us to keep a certain distance from patients. It is this distance that Dr. Awdish would like to diminish because it can easily lead to severe psychological wounding to patients. She describes many instances of this in her own illness experience where physicians made remarks in her presence such as, “She’s been trying to die on us.” As Dr. Awdish says, she was not trying to die, in fact doing everything that she could to avoid dying, and the impact of this remark was to distance her from her physicians and healthcare team, and to make her feel more isolated and alone.

Inperturbability and Aequanimitas

She then discusses William Osler’s essay, Aequanimitas, and quotes the phrase, “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril,” as the attitude that has led us physicians to the distance she finds so problematic. Much as I love Dr. Awdish’s book and agree with everything she has learnt and proposes, I completely disagree with her take on aequanimitas.

As she correctly notes, the phrase above describes imperturbability, or what Osler also calls, “phlegm.” I would describe it as non-reactivity. When something bad happens, we do need to be able to pause momentarily (a mindful pause) and prevent our body—and possibly our minds—being taken over by our immediate instinctual reactions. Imperturbability is an important first step in dealing with crisis.

What then is aequanimitas? Aequanimitas is the ideal response to a crisis in a fellow human being. As Osler describes aequanimitas, it is an empathic response: “the need of an infinite patience and of an ever-tender charity toward these fellow creatures; have they not to exercise the same toward us?” This does not sound like the kind of response that would lead a physician to say, “She’s been trying to die on us,” or, “She’s circling the drain,” as was also said about Dr. Awdish during her illness. So what is going on?

Four common reactions to stress

I believe that we need to become aware of what Osler did not describe, the common harmful reactions that we experience under stress or clinical crisis. Family therapist Virginia Satir would say that there are four main stress reactions, what she would call communication stances. When we interact with another human being and things are not going well, we may unconsciously blame the other person (blaming stance), blame ourselves (placating stance), deny our emotions (super-reasonable stance), or attempt to dissociate from the whole situation (distracting stance).

I can see evidence of some of these unconscious reactions in the wounding communications that Dr. Awdish experienced. For instance, “She’s been trying to die on us,” is clearly the blaming stance, and, “She’s circling the drain,” is probably the super-reasonable stance—denying emotion and describing a potential human catastrophe as simply water down the drain. The stances derive from a very simple model in which any interaction between two people involves three elements—ourselves; the other person; and the context. A stance results from leaving out one or more of the elements—blaming leaves out the other person; placating leaves out ourselves; super-reasonable leaves out both; and distracting leaves out all three.

Aequanimitas and Congruence

If, as I believe, aequanimitas is a conscious response, not an unconscious reaction, what does it correspond to in Satir’s terminology? It corresponds to what Satir would call congruence—presence to the other person; presence to ourselves; and presence to the context. This, I believe, is the ideal response in most situations, but particularly when we are stressed or in crisis. I believe if the physicians treating Rana Awdish had been mindfully congruent they would not have related in the damaging ways that she experienced.  Or perhaps, I should say, if they had understood and followed Osler’s dicta of imperturbability and aequanimitas.