Equanimity and the 25% Rule

A Country Doctor and his horse, Thanksgiving 2012

A Country Doctor and his horse, Thanksgiving 2012

Equanimity eluded me the other day after a string of challenging visits that each ran over its allotted 15 minutes. There was the man with a nonhealing lip ulcer that might be cancer, the elderly woman who decided to stay with her abusive husband, and the depressed pain patient whose lumbar steroid injections had not helped.

“Can I see you for a second”, Autumn said, peeking her head in after a discreet knock on the exam room door. She told me that Mauritz Blair in Room 1 had already left his room twice to express his dissatisfaction with my running late. I looked at my watch – only twenty minutes behind schedule.

“He said he’ll give you a few more minutes”, Autumn said. I shrugged and went back in the exam room with my waiting pain patient.

“I’m sorry about the interruption”, I said as I sat back down on my stool.

A few minutes later, I crossed the hall to Room 1. Mauritz Blair had been in a couple of weeks before with a longstanding, strange pain in his upper abdomen. I had ordered tests, which were all normal. I needed to come up with the next step in his workup. I wasn’t sure what to do next.

I knocked on the door and entered. Mauritz stood in the middle of the room with his arms crossed and turned an angry stare in my direction.

“What’s going on”, I said.

“Where have you been? I’ve been standing here without hearing any sign of life in this office for a long time. I was beginning to wonder if you were even here.”

I felt my indignation rise and heard myself blurting out:

“I’ve been seeing patients all day. Do you really think I’d keep you waiting on purpose? I had patients with big issues that needed some extra time. I’ve done that for you sometimes. Don’t you think I always do my best?”

He uncrossed his arms in surprise and I composed myself, trying to rescue the visit that had started with the two of us suspicious of each other.

I motioned toward the two chairs in the room and we sat down next to each other. I showed him the printouts of his tests and explained what each one meant.

“This could be what’s called Splenic Flexure Syndrome”, I began, and went on to explain the condition and some strategies to treat it. He listened quietly and I never did get a sense whether he thought my assessment and plan were reasonable.

“Why don’t you try these things for a couple of weeks, then we can follow up and see how they worked”, I said and entered my follow up request in the EMR.

He left without making another appointment.

That visit hung over me the rest of the day and after supper I confessed to my wife that I had failed in a visit by reacting with selfish indignation instead of trying to understand a frustrated patient. He could have been more worried than I realized, he could have had something else bothering him, or simply just been in a hurry. Just because he is retired, that doesn’t mean he doesn’t have time pressures just like I do.

I found myself, not for the first time, openly confessing to my wife that one of the few things about myself that I take too seriously is my commitment to my patients and my profession. I admit my procrastination at home, my vanity, my bad posture and all my annoying habits, but I have trouble accepting that some patients don’t think I try hard enough.

My wife listened patiently to my monologue. Then she spoke. I expected her to quote something from her Buddhist readings, which she did. But she first told me something evangelist Joel Osteen had said:

Only 25% of people really like you no matter what. 25% won’t ever like you. 25% like you conditionally, and 25% don’t like you unless you work at it. If you expect better odds, you’re unrealistic.

The Buddhist wisdom she shared about equanimity, one of the immeasurable qualities, was:

Equanimity in Buddhism means to have a clear-minded tranquil state of mind – not being overpowered by delusions, mental dullness or agitation. For example, with equanimity we do not distinguish between friend, enemy or stranger, but regard every sentient being as equal.
The near enemy is indifference. It is tempting to think that just ‘not caring’ is equanimity, but that is just a form of egotism, where we only care about ourselves.
The opposite of equanimity is anxiety, worry, stress and paranoia caused by dividing people into ‘good’ and ‘bad’; one can worry forever if a good friend may not be a bad person after all, and thus spoiling trust and friendship.
A result which one needs to avoid is apathy as a result of ‘not caring’.
Equanimity is the basis for unconditional, altruistic love, compassion and joy for other’s happiness and Bodhicitta.
When we discriminate between friends and enemies, how can we ever want to help all sentient beings?
Equanimity is an unselfish, de-tached state of mind which also prevents one from doing negative actions.

“If one tries to befriend an enemy for a moment, he becomes your friend.

The same thing occurs when one treats a friend as an enemy.

Therefore, by understanding the impermanence of temporal relations, Wise ones are never attached to food, clothing or reputation, nor to friends or enemies…” (The Buddha)


Sir William Osler put it this way:

“Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.”

As I quietly pondered all this, my wife said:

“Maybe in the exam rooms, somewhere near where the patients sit, you could hang on each wall…”

“A clock”, my mind raced to fill in. I had resisted that impulse for thirty years.

“….a picture of P.”, she said, referring to my Arabian rescue horse, who taught me patience with animals and showed me how to build trust by quietly sharing each other’s territory.

She’s right, if I can carry more of that patience with me into the pressure cooker of my workday, I may be more able to walk in the footsteps of Sir William, if not the Buddha.

1 Response to “Equanimity and the 25% Rule”

  1. 1 David Felker MD FACP December 10, 2014 at 11:54 am

    Wonderfully a propos. Today, if I think the patient encounter may be difficult, I’ll first consider which of the 25% they are to me

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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