EM Mindset – Stoic Philosophy for Emergency Physicians

By Sam Ko, MD, MBA (@drsamko, Assistant Professor, Loma Linda University Medical Center/ Co-Active Coach for physicians at www.lifecoachmd.co) // Edited by Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Stoicism is an ancient Greek philosophy founded in the early 3rd century BC by Zeno of Citium. This school of philosophy guides us towards a life of tranquility and virtue.  Tranquility is a state marked by the absence of negative feelings like anger, sadness, worry, and stress, and the presence of positive feelings – in particular joy.  Virtue is the aim for excellence as a human being living in accordance with nature.  Some of its historical proponents were Seneca, Epictetus, and Marcus Aurelius. More recent practitioners are Tim Ferriss, Ryan Holiday, and Scott Weingart.

Today, I’d like to share three Stoic exercises to make your life a bit smoother:

1) The View From Above

First take a deep breath in and out, then picture yourself from above. Almost like you are floating on the ceiling. You can see the top of your head from this view. Then slowly zoom out to your surroundings and see the people around you.  Zoom out again to see your city, state, country, and then Earth. Now go even further out and see the solar system, then the Milky Way, and then the whole cosmos.

Do you feel a bit small?  Miniscule?

Good. That’s the point.

Sometimes we need to step outside of ourselves and realize how we fit in the grand masterpiece of the Universe.  When we remember we are simply one of 7 billion people on Earth, which is contained in one of 100 billion galaxies, our anxieties and fears seem to get smaller.

2) Setting Expectations

Every morning, Marcus Aurelius would begin the day by telling himself, “The people I deal with today will be meddling, ungrateful, arrogant, dishonest, jealous and surly. They are like this because they can’t tell good from evil. But I have seen the beauty of good, and the ugliness of evil, and have recognized that the wrongdoer has a nature related to my own.”

He reminds himself to expect the worst behavior in people and that this is the natural order of life.  Also, he reminds us that they are not being this way intentionally and that we too have our faults.  As you know already, any patient presenting to the ED is probably not having the best day of their life and not at the best version of themselves either.  When we expect and accept the “meddling, ungrateful, arrogant, dishonest, jealous, and surly,” we will be much less disturbed.

3) Negative Visualization

Imagine that you are working a shift in your ED. During the shift, you get a phone call from the occupational health clinic. They tell you that your post-exposure blood tests from a needlestick injury have resulted. You need to come back for another test because you tested positive for HIV.  Moments later, you are pulled aside by the medical director. He tells you that the group lost the contract renewal and all providers are losing their job.  On your way home, you get a phone call from your spouse. Your partner isn’t happy in the relationship and is leaving you for someone else.  As you put the phone away, you look up to see the red brake lights of the car in front of you. You slam on the brakes. CRUNCH! The airbags burst open in your face and your hood is on fire.

*Record scratch*    *Freeze frame*

Stoic philosophers believe we can appreciate more of what we have by imagining ourselves without. The hedonic treadmill of adaptation leads us to want more and more. We get the iPhone 7 then a few months later the iPhone 8 comes out. Imagine having to stop at a pay phone for phone calls on the road and carrying those foldable maps with us on roadtrips.

Using negative visualization a few times week can help remind us that the things we treasure are “like the leaves on a tree, ready to drop when a breeze blows.”

To summarize, remind yourself to take a larger perspective on life. Remind yourself to expect all sorts of people so you’re not surprised in the emergency department. And occasionally imagine what your life would be like without your current blessings.

Finally, know that Stoicism is a practice and a habit that develops over time. Alongside your trusty stethoscope, bedside ultrasound, and medical smartphone apps, Stoicism is another tool to add to your mental armamentarium.

References / Further Reading

1. Aurelius, M. 2015. The Meditations of Marcus Aurelius. Sweden: Wisehouse Classics.
2. Irvine, W. 2008. A guide to the good life: the ancient art of stoic joy. Oxford, England: Oxford University Press.
3. Pigliucci, M. (2015, Feb. 2) How To Be a Stoic. New York Times. Retrieved from: https://opinionator.blogs.nytimes.com/2015/02/02/how-to-be-a-stoic/?_r=0
4. Pigliucci, M. Stoicism 101. Retrieved from: https://howtobeastoic.wordpress.com/stoicism-101/
5. Robertson, D. (2011, Aug. 13) The View From Above. Retrieved from: https://philosophy-of-cbt.com/2011/08/13/the-view-from-above-stoic-meditation-script/