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“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
It is important to reflect occasionally on where one’s path began inasmuch as we owe a debt to those who have advanced our current purpose, whether family, business, or profession. The goal of this reflection should hopefully include an appreciation of the sacrifices of those who blazed the trail ahead of us as well as a critical appraisal of current efforts to ensure mistakes of the past are not repeated.

William Osler, considered to be one of the fathers of modern medicine, (Halstead, Kelly, and Welch were the other renowned faculty members at Johns Hopkins in the late 19th Century) was known for actually bringing medical students to the patients on rounds and for starting the first formal residency program. To give you some historical perspective, during the late 1800’s, Halstead was just starting to use cocaine (personally as well as on his patients) as an anesthetic; aseptic technique in the operating room was being practiced only at Hopkins; and wealthy patients had surgery in their own homes.

It was during this era (1889) that Osler gave a farewell valedictory address titled Aequanimitas to the medical students at the University of Pennsylvania when he left to become the first physician-in-chief at the Johns Hopkins Medical School.

The address focused on two related words, aequanimitas and imperturbability, which, according to Osler, may be the two most important traits a physician can possess:

In the first place, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue. Perhaps I may be able to give those of you, in whom it has not developed during the critical scenes of the past month, a hint or two of its importance, possibly a suggestion for its attainment. Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness …

The virtue of aequanimitas (which Osler considered the mental equivalent of imperturbability) not only is vital in the practice of medicine but also serves us well in other pursuits, particularly as they relate to the development and operation of urgent care centers. As with all important endeavors, the clause “if it were easy, everyone would do it” is true for practicing medicine and opening and operating urgent care centers.

The challenges experienced surrounding the day-to-day operations of centers can certainly cause an owner/operator to be much less than calm by the end of the day. The vagrancies of patient flow and resultant revenue fluctuations; the idiosyncrasies, diverse backgrounds, and education of the staff; and the challenges of payer reimbursement make operating urgent care centers ill-advised for the weak-willed.

Over the years spent in the ED and managing urgent care centers, I have witnessed the occasional provider and more than a few urgent care operators become unhinged during real or imagined crises. Nothing does more to raise the anxiety of patients or employees than to see the person whose expertise upon which they are reliant “lose it.” Despite its clear necessity, I am uncertain if calmness under pressure comes from genes or training. Osler had this to say:

As imperturbability is largely a bodily endowment, I regret to say that there are those amongst you, who, owing to congenital defects, may never be able to acquire it. Education, however, will do much; and with practice and experience the majority of you may expect to attain to a fair measure. The first essential is to have your nerves well in hand. Even under the most serious circumstances, the physician or surgeon who allows “his outward action to demonstrate the native act and figure of his heart in complement extern,” who shows in his face the slightest alteration, expressive of anxiety or fear, has not his medullary centres under the highest control, and is liable to disaster at any moment.

How then does one become the face of serenity during the storm? Clearly, training and experience count for much; I can remember my hand trembling the first time I sutured a patient or delivered a baby. I like to think that after the first few seconds I regained my steadiness that the patient’s laceration eventually healed and the child was born without shaken baby syndrome.

In a true and perfect form, imperturbability is indissolubly associated with wide experience and an intimate knowledge of the varied aspects of disease. With such advantages he is so equipped that no eventuality can disturb the mental equilibrium of the physician; the possibilities are always manifest, and the course of action clear. Keen sensibility is doubtless a virtue of high order, when it does not interfere with steadiness of hand or coolness of nerve; but for the practitioner in his working-day world, a callousness which thinks only of the good to be effected, and goes ahead regardless of smaller considerations, is the preferable quality.

A friend of mine once said that the key to happiness is a short memory and low expectations. Over the years, and particularly over this last year, this admonition saved a couple of non-notables from an untimely demise. For whatever reasons, there are a few hapless individuals, patients and otherwise, I have met along the way, who, despite their remarkable lack of the basics of human niceties and professional behavior, deserve pity as opposed to scorn.

How difficult to attain, yet how necessary, in success as in failure! Natural temperament has much to do with its development, but a clear knowledge of our relation to our fellow- creatures and to the work of life is also indispensable. One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell. “Knowledge comes, but wisdom lingers,” and in matters medical the ordinary citizen of today has not one whit more sense than the old Romans …

For anyone who has started a venture that ultimately failed or for those who struggled but were eventually successful, take some comfort in that, at the end of the day, you are better for the effort, whether it was a success or a failure. It is sad to think that, for some of you, there is in store disappointment, perhaps failure. You cannot hope, of course, to escape from the cares and anxieties incident to professional life. Stand up bravely, even against the worst. Remember, too, that sometimes “from our desolation only does the better life begin.” 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. It has been said that “in patience ye shall win your souls,” and what is this patience but an equanimity which enables you to rise superior to the trials of life.

I find it fascinating that 112 years after Osler sent off the medical students with aequanimitas, as a profession we still occasionally have to be reminded that despite some of the challenges with Osler’s stilted diction, his remarks still hold true: for urgent care physicians and owners, imperturbability and aequanimitas, whether acquired or developed, are incredibly beneficial traits that will make the transit through this life much more enjoyable.

Or, if Osler is a bit prosaic, as Judge Elihu Smails said in Caddyshack: “It easy to grin when your ship comes in and you’ve got the stock market beat. But the man worthwhile, is the man who can smile, when his shorts are too tight in the seat.”
*Aequanimitas = equanimity (Latin).

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