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Modern Medicine and Modern Stoicism

December 30, 2021
Elizabeth Brém, MD
Assistant professor of medicine at University of California Irvine Medical Center in Orange, CA

One of the things I have found myself particularly struggling with as a fairly new attending is accepting that patients are free to make what I think are poor decisions. For example, I recently had a young patient with relapsed but chemotherapy-sensitive Hodgkin lymphoma refuse an autologous transplant, despite multiple opinions across the country advising the transplant. I also care for an older but very active patient with relapsed myeloma whose family convinces her to take supplements in lieu of approved therapies. I could go on and on, and I'm sure others have similar examples.

I suspect that trainees and junior attendings are particularly vulnerable to taking these situations personally, since many of us are still suffering from impostor syndrome – doubting our accomplishments and fearing exposure as a fraud. I find myself wondering, "Maybe I didn't explain things well enough?" or "Maybe I could have been firmer?" I have no doubt that a subconscious fear of litigation also adds to some of the anxiety and discomfort that we feel when patients choose not to take our advice.

After my first son was born, I was introduced to Stoicism as a potential tool to help me be more "in the moment" and less distracted. Initially, I was skeptical about how not displaying emotion would be helpful, but I was tired enough to try showing the baby my poker face.

It turns out that emotionlessness, the colloquial definition of being stoic, is a mischaracterization of "capital S" Stoicism. The Stoic philosophy was founded in ancient Greece by Zeno of Citium and was expanded upon by philosophers such as Marcus Aurelius, Seneca, and Epictetus. Stoicism focuses almost entirely on navigating difficulty and teaching the practitioner to be as happy in the worst of times as in the best. It strives to help people be grateful for what they have and prioritize one's personal values, rather than suffering over unchangeable and uncontrollable outside forces.

The goal of practicing Stoicism is to be more in control of one's reactions – trying to see the positive in situations rather than getting caught up in the negative. Eventually, difficulties and undesired results are recognized as useful information, rather than regret, irritation, or self-judgment. Struggles and difficulties are part of the journey.

Since I was introduced to the philosophy, I have found that journaling and ruminating on Stoic ideals has helped me be more grateful, less judgmental, and less prone to getting caught up in drama – which is a big feat for someone who was involved in theater through high school and college!

I am amazed that the ideas explored by philosophers thousands of years ago are still so applicable. Our medical training can already be considered fairly Stoic. Seneca wrote that "Nothing should ever be unexpected by us. … We shouldn't just consider the normal course of things, but what could actually happen." Applied to medicine, as trainees, we practice running codes. We develop broad differential diagnoses and change that differential as data are gathered. We test hypotheses in experiments or clinical trials and revise said hypotheses based on the data obtained. We explain the risks of chemotherapy to patients and ask pointed questions about major toxicities at every visit.

The Stoics even had advice for work-life balance. Marcus Aurelius suggested that, before saying or doing anything, we pause and ask ourselves, "Is this one of the necessary things?" Interestingly, "Learn to say no" was the most common piece of advice I got when transitioning from trainee to attending.

I am reminded of the Serenity prayer: "Grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference." As doctors, we know how to triage patients, but we could all benefit from also "triaging" our worries. Time and thoughts are finite and precious. Why spend them stressing about outcomes outside our control? A level head always allows us to see the next patient or next important decision with clear eyes. So, kiss your kids, have a glass of wine, think of all the people you helped today, and thank the team at work and in life who help you do your job and be the person you are. Gratitude is one of the most important emotions in building happiness. I've been amazed by how my attitude and outlook can change with little bursts of gratitude.

Because I am trying to practice Stoicism, I am fully aware that you, reader, are welcome to take or ignore my column; I can't control your reaction to this editorial. For all I know, some of you out there have been practicing Stoics for years!

However, if I can encourage you to take just one piece of advice, I recommend accepting that all we can do is try to understand our patients' concerns, share our expertise, and answer questions to the best of our ability. Be kind, be approachable. Practice serenity. Speak plainly (see Mikkael Sekeres' December 2018 Editor's Corner, "My Fair MDs: Encouraging Doctors to Speak Plainly," for details).

Per Seneca, "Don't seek for everything to happen as you wish it would, but rather wish that everything happens as it actually will." (I struggle with that concept more than I care to admit.) For better or for worse, document that you did your best to advise the patient of the best evidence-based therapy for the situation. Be there with open arms and an open mind when the patient comes back to you, and be grateful that patients let us into their lives every day.


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