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14. Stoic With a Capital S

When we hear the word stoic, what often comes to mind is a repression of emotion, a stone-faced response to adversity. You can think of that kind of stoicism as using it with a lowercase 's'. What we're talking about today is the philosophical school of Stoicism, Stoic with a capital 'S'. At its core, Stoicism provides a way to find equanimity no matter the circumstance and take on whatever adversity is thrown at you.


Our Guest: Dan McCollum, MD is an award winning educator and assistant professor of emergency medicine and Augusta University. His translation of philosophical ideas into real world practice (both in and outside of medicine) have garnered international acclaim. Dan was our guest on Stimulus episode 1: Verbal Judo.





We Discuss:


What’s the difference between stoicism (with a lowercase “s”) and Stoicism (with a capital “S”)?

  • Lowercase stoicism refers to the repression of emotion and ability to remain stone-faced in response to adversity. Modern psychology tells us that if we repress emotion, not only are we not doing something beneficial, but we’re probably doing something actively harmful.

  • Upper case Stoicism is a school of thought which provides a way to find happiness while at the same time taking on whatever adversity is thrown at you. This philosophy recognizes and deals with emotions rather than suppresses them.

  • Stoicism tries to distinguish between what’s in your control and what’s not in your control.

  • Epictetus wrote, “Stoicism is to make the best of what is in our power and take the rest as it naturally comes.”

  • Martha Washington expressed a Stoic belief when she said, “The greater part of our happiness or misery depends upon our dispositions and not upon our circumstances.”

There are 3 disciplines of Stoicism.


The discipline of desire. This is acceptance of your fate and knowing that bad things are going to happen. This provides growth opportunity.

  • This is expressed in Jocko Willink’s video, Good. If something bad happens, say “Good”. Then get up, dust off, reload, recalibrate, re-engage.

  • It’s also similar to the Serenity Prayer. “Grant me the serenity to accept the things I cannot change; courage to change the things that I can; and wisdom to know the difference.”

  • Wishing that things that are rough in this world didn’t exist will get you nowhere. Instead of dwelling on or complaining about the bad things, try to productively do something about it.

  • Acknowledge that rough things will occur, and when they happen decide if it’s something you can change or something you need to accept.

The discipline of action. This discipline teaches a love for mankind. The fundamental tenet is that you should live a life of excellence and always choose virtue.

  • Anything that distracts you from virtue is an unhealthy passion and, therefore, is bad. And anything that prevents you from doing the right action to serve your fellow man is something that is negative.

  • As an example, it’s not a problem to want money. But if you’re willing to sell your soul in order to get more money, then the money is detracting from your virtue.

  • The Stoic philosophy asks you to look not only for ways that you can improve yourself, but also for ways that you can improve mankind. Stoics truly love their fellow man and preach the idea that we have to serve other people as if they were yourself.

  • Stoic beliefs overlap with Eastern philosophies, having a strong idea of interconnectedness. We are all humans, and we all matter equally.

The discipline of assent. This is mindfulness of our judgement. It teaches that we want to live according to reason, be truthful in thought and speech, and remain objective.

  • When bad things happen, it’s our judgement of what happened that disturbs us more than what actually occurred.

  • A closely related aspect is the idea of an inner citadel which is a fortress within us that no challenging circumstances can disturb.

  • As long as you continue to act virtuously, you’re living a good life.

How can you apply the Stoic principles to common (unpleasant) scenarios in the ED?


Scenario 1: You’re working a tough shift and there are 40 people in the waiting room. You can’t get patients admitted and you feel stuck.

  • Marcus Aurelius helps frame a way to think about this: “Remember: Matter, how tiny your share of it. Time, how brief and fleeting your allotment of it. Fate, how small a role you play in it."

  • If you zoom out far enough and look at your situation relative to the universe, ask yourself, “While tough, is what’s happening right now really unbearable in the big scheme of things? If I zoom out far enough?”

  • When you’re having a difficult shift, it’s easy to get bogged down by the fact that things aren’t going smoothly. But if you just focus on the tasks that are within your locus of control, time will pass quickly. This is better than wasting energy trying to come up with ways of fixing the whole system and things outside of your control.

Scenario 2: Dealing with the difficult consultant.

  • Marcus Aurelius: “Someone hates me. Their problem. Mine: to be patient and cheerful with everyone, including them.”

  • If you’ve been disrespected or treated rudely, don’t react by mistreating the person in return. Try to be patient and cheerful with everyone, no matter how hard that is.

Scenario 3: A consultant recommends a treatment that is counter to what you believe is in the patient’s best interest.

  • Be flexible and share your opinion in an objective way.

  • If someone criticizes you, avoid letting your ego get in the way of proper patient care. Be open to the possibility that you might have something to learn.

  • Stephen Covey: “First seek to understand. Then be understood.”

  • Allow the consultant to explain him/herself. If you wield your ego like a club, the conversation is over. Nothing is going to happen except conflict.

Scenario 4: A colleague begins a conversation with, “Remember that patient you saw last week with chest pain…”?

  • The initial negative reaction where your stomach sinks is psychologically normal. It’s just going to happen. What you do with that reaction is where your choice comes in.

  • Lowercase stoicism would tell you to repress this response and pretend like it didn’t happen.

  • Uppercase Stoicism provides a healthier reaction. Acknowledge whatever error may have happened (if one did) and then learn from it. Is there something you could have done differently, or was this just a freak occurrence that was fated to happen?

  • Don’t be arrogant. If you are liked by your patients and you genuinely show that you care, very few of your complaints will stick in a way that matters to you.

What is the best way to develop some of the Stoic habits and responses to stress?

  • With Stoicism, you have to accept that life is full of things that will be painful. If you can intentionally accept that some things will hurt, yet trust won’t cause harm because you’re living a life of virtue, you will grow accustomed to some of the rough things that happen.

  • By experiencing difficulty, you will build up your resistance to minor episodes of pain and you’ll gradually grow “thicker skin”.

  • Tools to help develop a Stoic philosophy

  • Meditation

  • 5 minute journal

  • Practicing gratitude for the small things

How does a Stoic process anger?

  • We all feel anger from time to time, but we have a choice in how we respond.

  • In the Stoic system, the things that are worthy of our focus and attention are the things that are in our direct control. If you’ve been insulted by a colleague or cut off by a driver, their actions are not in your direct control. Therefore, in Stoic thinking, these actions are not worthy of your consternation.

  • We will inevitably feel anger, and there are a few steps within Stoicism to help in our response to it.

  • Self-monitoring -- Mindfulness practice can help you get in tune with your emotions and what’s going on in your mind. Through meditation, you will learn to check in with yourself, asking “Am I beginning to feel angry? What does that feel like?”

  • Distancing yourself from the event -- It’s not what happened that made you angry. Instead, it’s your perception or judgement of the event that caused anger. When you recognize that you feel anger, pause before acting on it.

  • Reflect on your response -- Think about what a response in anger would look like vs. a virtuous response, such as compassion or kindness.

References:

  • Robertson, Donald. How to Think Like a Roman Emperor: The Stoic Philosophy of Marcus Aurelius. St. Martin's Press, 2019.

  • Aurelius, Marcus. "Meditations (G. Hays, Trans.)." New York: The Modern Library (2002).

Shownotes by Melissa Orman, MD


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