Contrary to contemporary understanding of stoicism and the modern use of the adjective ‘stoic’, stoicism is minimally concerned with the stern renunciation of emotional responses. While tolerance and self-control are important elements of the philosophy, stoicism may be best understood as a means to a virtuous life through the recognition of what is within versus outside of our control. Understanding both our environments and ourselves is imperative to steering our work, our relationships, our expectations, and – perhaps most importantly – to determining where and how we can contribute to the greater good. Below is an incomplete exploration of how the stoic perspective may benefit the medical trainee in 2020.
Distilled to its most basic elements, stoicism is about the dichotomy of control: the acknowledgement that there are certain things that are within our control, and others that are outside of it. In general, we are in control of our beliefs, behaviours, judgments, perceptions, and desires; conversely, our reputation, and the thoughts, beliefs, and behaviours of others are outside of our control. The responsibility of stoic individuals is to classify the elements of their lives accordingly in order to invest their time and energy into things that can be modified by their investment. It is imperative to recognize that our ability to convert things across the dichotomy of control is generally very limited.
The dichotomy of control can be applied to interactions both with patients and ourselves. Consider two scenarios:
- A 68-year-old male of elevated BMI, with substantial smoking history, poorly controlled hypertension (175/95 mmHg), and type II diabetes (HbA1c 9.2%) refuses lifestyle modification advice and pharmacologic management from his physician; at present, he is asymptomatic.
- Since the onset of pandemic-related restrictions in clinical duties and practice, the clinical duties of a medical trainee have been either drastically modified, or completely uprooted. The trainee’s sense of purpose has waned, and they wonder when they will be able to return to normal life and if the pandemic will affect their career prospects.
We can reasonably discern the aspects of each scenario that we can control. While our preliminary reaction to the patient might be frustration, anger, or confusion, these feelings are rooted in the false belief that we have control over another individual’s behaviour. Is it not angering, after all, that an individual would refuse life-improving and life-extending treatment? For better or for worse, the reality is that we have only partial control over the direction of conversation for a fraction of the patient’s day. Thus, to expect every patient to be 100% compliant with each of our suggestions is probably unrealistic. However, we have absolute control over the language that we use to communicate with the patient while he is in the office; we have control over the types of questions we ask the patient; and we have control over the emotions we project toward the patient; all of which may have real effects not only for the patient’s acute experience, but also his longitudinal trust in healthcare.
In matters that concern our own lives, it is even more difficult to remain resolute in our acknowledgement of the dichotomy of control. As medical trainees, we often endorse the notion that much of our success is due to our own volition, our own strong will and discipline. Any barriers to our ambitions appear to set ablaze the script of our lives. The pandemic has caused curricular reform, cancellation of electives, and a loss in the momentum of sharpening clinical acumen, and there is no degree of individual will or discipline that can reverse a global pandemic. Perhaps this circumstance can serve as a reminder that much of how our life has advanced has been a push and pull – or perhaps more aptly, a “grasp and let go” – of control. While we may have put ourselves in positions to succeed throughout each stage of our lives, it was largely the decisions of others – admissions committees, student body voters, high school teachers, coaches, etcetera – that propelled us into the positions that we currently occupy, and will occupy in future stages of our professional and personal lives. Relinquishing a desire for control over the pandemic is the only reasonable course of action, given that we never had control over most of the logistics of our experience to begin with.
It goes without saying, of course, that maintaining these beliefs in control is progressively more challenging the worse the situation becomes. If this patient was to suffer from a STEMI, ischemic stroke, or pulseless limb in the coming months, we would feel an understandable culpability in his misfortune. Similarly, if an applicant goes unmatched this upcoming cycle, they may feel a certain anger toward the lack of visiting electives they had this year.
But the reality is that these are narratives. While it is cognitively soothing to attribute a single event to a single cause, the lives of ourselves and others are multifactorial and complex. We may never know why the patient lost his leg, or why we went unmatched. Stoicism, let alone the dichotomy of control, has no response for this.
Its only response is simple: over what part of this situation do you have control?