On William Osler, Psychiatry, and the Law: Reflections on "Aequanimitas" at 130 Years

At the beginning of my second year of psychiatry residency training, I stood before the large and somewhat formidable brick structure with the words "Santa Clara County Superior Court" cleanly engraved in the frieze. I made my way through the courthouse’s security gates, found my assigned courtroom, and introduced myself to the appointed counsel. I approached the bailiff, swore to tell the truth, and took my seat on the witness stand.

A rush of apprehension came over me. By this time in my training, I had encountered numerous tense situations with agitated patients or angry family members in the hospital. But this felt different. I was outside my clinical environment, expected to give an official court testimony—a dictated account that not only would find its permanent home in the court record but would ultimately be used to inform a court’s legal decision.

Soon after I took the stand, the opposing counsel—the one representing the patient—followed my attorney’s gentle inquiries of me with a barrage of fiery questions. He asked questions about my medical training and the hospitals where I had worked, whether I possessed an active medical license, my previous experience in legal matters, and whether I made independent clinical decisions as a physician-in-training. Perhaps the most pointed line of questioning pertained to the accuracy (or legitimacy) of my patient’s psychiatric diagnosis—one I had arrived at without the aid of high-tech imaging tests or laboratory studies. The experience felt more adversarial than collaborative, and I felt an urge to defend myself. Recognizing these reactions, I suddenly recalled words of advice from my attending psychiatrist: "Just stay calm and composed. Don’t react."

In his 1889 valedictory address to the medical students at the University of Pennsylvania, renowned physician Sir William Osler (1849–1919) urged the aspiring physicians to cultivate a sense of "aequanimitas," which he defined as "coolness and presence of mind under all circumstances" (1). A physician without the ability to weather the storm with calmness, he argued, "[was] liable to disaster at any moment" (2).

Like any good physician, the psychiatrist has much to learn from Osler. Osler wrote that "imperturbability…is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it…loses rapidly the confidence of his patients" (3). Judges and juries observe just a cross-section of a physician’s demeanor and behavior on the stand—and virtually none of a physician’s bedside manner. They do not share the moments in which physicians sit with patients at the bedside, bearing witness to patients’ suffering. And equally important, they are not privy to the moments that give physicians pause, the experiences in caring for patients that remind us of our shared humanity and our duty to one another. For these observers, a physician’s inconsistency in describing a patient’s hospital course or symptoms, defensiveness about a clinical decision, or less than empathic responses about a patient’s illness experience might undermine the trust and confidence that these members of the public place in physicians.

The court ultimately sided with the physicians, helping the patient receive needed care. Nearly a year after my court testimony, I am still struck by the applicability of Osler’s guidance for physicians across medical settings and specialties. Whether at the bedside or in the courtroom, Osler called on us to cultivate equanimity—to develop "firmness and courage, without, at the same time hardening the human heart by which we live" (2, 3)—perhaps the physician’s greatest virtue. And it is one that calls out as strongly today as it did 130 years ago.