Aequanimitas in Facing Death

…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.¹

In his farewell address to graduates of the University of Pennsylvania's School of Medicine, William Osler emphasized the importance of maintaining composure and clarity of thought under moments of duress. But achieving this equanimity, or Aequanimitas, can be a staggering task for younger physicians in training. Despite years of challenging course work and hours of dedicated studying, trainees often feel ill-equipped to navigate the more nuanced aspects of advanced patient care. Some feelings of inadequacy are a requisite part of maturing into a competent physician, but if persistent, they may suggest a deeper problem.

Impostor syndrome, a behavioral phenomenon characterized by chronic self-doubt and an inability to internalize accomplishments despite an evidence of abilities, is being increasingly recognized among medical trainees and healthcare professionals.² In a survey of 138 medical students, nearly 75% of participants feared being revealed as frauds and downplayed the significance of their achievements.³

I came face-to-face with my own version of impostor syndrome during the first year of my training. Due to changes in duty hours, first-year trainees were not allowed to remain in the hospital overnight to admit patients. Though initially appealing, this ultimately made for a hectic and disorganized post-call day that involved putting together the pieces of complex overnight admissions that we had little knowledge of firsthand.

M was one such patient who had been admitted overnight with altered mental status and decompensated cirrhosis. “We just need to keep him comfortable,” my resident had assured me. What she meant was that M had an advance directive that instructed us to forgo any life-sustaining measures or invasive procedures in the event that his heart stopped.

As M's mental status had already started to improve, he was the last patient I checked in on. To my surprise, I found him slumped over the side of his bed, moaning in pain. It was only when he sat up and clutched his chest that I realized just how yellow his eyes were. I remember the distinct feeling that I was staring into the face of death. The events that followed were a blur of emesis basins, blood-soaked towels, harried nurses, and M's room number being called frantically overhead.

Before I knew it, M was transported to the intensive care unit. The on-call gastroenterology fellow began arrangements for an urgent endoscopy—a procedure that would allow him to visualize and potentially intervene on M's bleeding source. Amidst the chaos, it took me much longer than it should have to speak up about M's goals of care. I had only read about variceal bleeds in textbooks. I was still in my first year of medical training. I was female. But I had just as every right to be a part of M's care as anyone else in that room, more importantly I knew this was not how M had envisioned the end of his life. I managed to convey my concerns to the critical care team, and M was officially transitioned to “comfort care.” But what exactly did that mean in M's case? We knew he wanted to avoid invasive measures, but he clearly wasn't comfortable. I could tell that he recognized none of us and felt utterly terrified. Together, we agreed to provide M with nasogastric suction, anxiolytics, and oxygen while I tried to reach his estranged family by phone.

At this point, I had no time to fixate on any feelings of self-doubt. I remained composed when M's father remarked on how young I sounded, hinting at my likely inexperience. I feigned confidence when I described the source of M's bleeding to his exasperated wife. I didn't let my voice waver when I explained to M's son (who lived three hours away) that he would likely not see his father alive. And I remained calm when he collapsed in my arms three hours later. The dreaded moment of reckoning when everyone would realize that I had no idea what I was doing never came.

The difficult conversations and challenging cases I have encountered since M have been too numerous to count. In caring for a patient population that is often twice my own age, I have often had to double my efforts to display constant composure to earn my patients' respect. Although I have made mistakes along the way and continue to have regrets, avoiding uncomfortable situations has not been one of them.

In her thoughtful essay published earlier this year, Dr. Suzanne Koven recounts her own struggles with impostor syndrome as a cautionary tale to a hypothetical young female physician. She provides honest and specific examples of moments when she perseverated on her perceived inadequacies and downplayed her strengths. Dr. Koven ends by acknowledging that instead, she “should have spent less time worrying about being a fraud and more time appreciating about [herself] some of the things [her] patients appreciate[d] most about [her].”⁴ Trainees should be encouraged to do the same as they navigate the difficult conversations and situations that arise during advance care planning.

Every Christmas in residency, my program director had the generous habit of giving each of his residents a book which he personally inscribed. During some of my more stubborn moments of self-doubt or fear, I still read excerpts from the gift I received, Osler's “Aequanimitas.”