Applied Stoicism

Ancient Philosophy for Modern Emergencies

How to train yourself to think clearly and act skillfully during stressful situations

Dan Dworkis, MD PhD
Dec 10, 2019 · 17 min read
“Aftermath of a resuscitation.” Photo by Dan Dworkis, MD-PhD

For a moment, put yourself in these shoes: You are the leader of the resuscitation team, the head doctor in the ER.

By the time the patient arrives in your emergency department, he is barely breathing and covered in blood. The paramedics tell you he was crossing a street when a car ran a stop sign, sending him flying off the road. On the gurney, his breathing is shallow and ragged, his heart is beating too fast, and his blood pressure is too low. The outlook is grim at best. Unless you and your team make the right moves in the next few minutes for this man, they might be his last.

Can you feel the weight of the moment and eyes of your team on you? What do you do? How do you handle the pressure and the weight of making decisions during a crisis? Even if you had all the medical knowledge in the world at your fingertips, would you be able to deliver it to the patient with all the chaos around you?

In reality, you are likely not an ER doctor; maybe you never resuscitate a critical patient, but you find yourself trying to negotiate a crucial point in a contract with jobs on the line and the clock ticking down. Maybe you’re trying hard to understand your partner and work through a difficult time, or you’re sliding on a patch of black ice trying to dodge an oncoming car. Whatever circumstances you face, are you able to perform at your best when you find yourself in a real crisis?

As an emergency doctor — and as a human — I am constantly thinking about how I can get better at applying knowledge under pressure. I believe that the purpose of learning and growth is not to get better at storing up facts but to understand things so deeply that we can bring them to bear where and when we need them in the reality of our daily lives. I also believe that applying knowledge under pressure is a skill that everyone, ER doctor or not, can train and get better at.

So, I ask myself: How can I perform better when I am needed the most? How can I train myself and my teams to deliver the best possible emergency care to our patients, to think clearly and act skillfully during situations that are full of uncertainty and stress?

Some of the best answers I have found to these questions come not from a medical textbook or a scientific journal, but from the teachings of the Stoic philosophers. The Stoics — Greco-Roman philosophers like the Roman emperor Marcus Aurelius, the writer and statesman Seneca, and the former slave Epictetus — lived a way of life that centered on finding joy and strength by acting from within, accepting the transience of existence, and letting those things outside our control do what they will.

We don’t usually teach stoic philosophy in medical school, but we should.

As doctors, we need to learn it. In fact, I believe we all do. The core tenets of Stoicism — understanding personal responsibility during hard circumstances, fearless action in the face of uncertainty, and finding joy from within — are indispensable during a crisis, no matter if that crisis is a crashing patient in the emergency room or an unexpected technical failure that threatens to derail your business.

So, here are five stoic ideas that I focus on in my own training, ideas that I actively use during an emergency. I work through them with the doctors I help to train, with my teams during a critical case, and with myself, over and over again.

Of course, reading Stoic philosophy will not, by itself, enable you to lead a team of doctors and nurses in responding to a car accident. If you study these principles, though—if you really build them into your daily life and dig deeply into what they mean for you—I absolutely believe that you will be better able to think and act when you are needed the most.

“The closer a [person] is to calm, the closer [he or she] is to strength.” — Marcus Aurelius

Photo by Thao Le Hoang on Unsplash

To stay calm and collected in the face of suffering, uncertainty, and chaos, to bring the best of ourselves to bear no matter the external circumstances is one of the main goals of emergency doctors and Stoic philosophers alike.

The more we can control our reactive mind and maintain a state of poise and grace under pressure, the better we are at deploying our best self when we are needed most. Conversely, when we are out of control, we are lost. As W. Timothy Gallwey put it in his classic The Inner Game of Tennis, “Relaxed concentration is the supreme art because no art can be achieved without it, while with it, much can be achieved.”

There’s a French word that perfectly holds this concept: sangfroid. A combination of the word sang, meaning blood, and froid, meaning cold, sangfroid literally means cold-blooded. What it really means, though, is the ability to stay calm in the face of chaos, to hold fast and stay cool when everything around you is going off the rails.

At first glance, it might seem that sangfroid is some innate gift, that some people are simply born with the ability to keep their wits about them and some are not. The idea of trying to save this man who was hit by a car, or, for example, of surviving a night in the woods with limited resources after getting lost might seem difficult or even completely overwhelming. It would be easy for someone to conclude that being calm in these types of situations is just not in their skill set.

However, after years spent working on developing sangfroid in my own life — and more recently, training other doctors on how to develop their own sense of sangfroid — I am convinced this is just not true. Sangfroid is not an innate gift. Instead, it is a skill that each of us can train and, with time and practice, come to excel at.

Part of why this first Stoic quote stays with me is what it does not say: Aurelius does not say strength only comes at the end, when we are perfectly calm. Instead, he suggests there is a gradient — the more sangfroid we can bring to a situation, the better we can respond. Most of us don’t have to start by running a full trauma team immediately; instead we can build our sangfroid piece by piece, finding our strength each step of our way.

So, start small and get moving. Start today. When you’re confronted by something in your daily life that makes you uncomfortable or uncertain — a challenging situation at work or an argument with a loved one perhaps —pause and take a breath, reflecting on calmness as a deep source of your strength.

If you don’t already have a calming technique that works for you, consider trying “tactical breathing,” which is designed to slow your heart and help you calm your mind. The basic idea of tactical breathing — also called “box breathing” — is to visualize a square, where each side of the square is one part of the breath. The length of each side corresponds to the amount of time that part of the breath takes, and as you breathe, you mentally move yourself along the edges of the square.

A full circuit of tactical breathing looks like this: breathe in for four counts, hold your breath for four counts, breathe out for four counts, hold the breath out for four counts. When something chaotic arrises, use several circuits of tactical breathing to come back into contact with a deeper calm. With deeper calm, you will find more strength for whatever happens next.

You don’t have to be a master of meditation to handle yourself during a crisis. Just remember that the closer you are to a calm mind, the better you will respond, and that — no matter where you start — you can build sangfroid with dedicated practice.

“Between the earth and the stars, there is no easy path.” — Seneca

Image by PTNorbert.

There is nothing easy during an emergency. There is nothing easy about our patient having been hit by a car, nothing easy about the work we will do to try to stabilize him. It is easy to be upset about this, to be angry at the driver, to wish our ER were better equipped for a serious trauma, to want things to be different. But they are not different.

This, right now, is what we have to work with, and time spent wishing things were different is time not spent doing what needs to be done. In this universe, there is no easy path between the earth and the stars — therefore if we want to go to the stars, we must be willing to take the steps required to get there.

In other words, if we want to be able to respond better during an emergency, we must expect and train for hardship.

Rather than devote energy to looking for an easy path that does not exist, this second Stoic quote reminds us to prepare ourselves for hard work, to steel ourselves for the difficult things that are going to come our way.

The Stoics might call this premeditatio malorum, the act of purposefully thinking through the absolute worst, most difficult things one might encounter in an endeavor in an effort to better prepare for them.

In the moments before a crisis strikes, we can think ahead about difficulties we might encounter and identify potential deficiencies in our back-up equipment, or proactively make ready the right doses of medications we think we might need to deliver. In the days and weeks before a crucial product launch, we could drill through common scenarios and identify areas for potential improvement.

In the business world, this tactic of imagining the death of a project before it starts and then working backward to analyze why it failed is often called a “premortem.” It can be a very powerful technique to prepare ourselves and our teams for potential critical issues before they arise.

Initially, purposefully thinking about all the difficult things that could go wrong might seem morbid or overwhelming, especially if you jump immediately to the worst possible situations. On a recent podcast episode, Lieutenant Amy Hildreth — a fellow emergency doctor and the Emergency Medicine Simulation Director at the Naval Medical Center in San Diego — suggested that people overcome this barrier by starting not with the most difficult situations, but with a situation just beyond what they are 100% sure they could already handle.

You don’t need anything specific to get started practicing premeditatio malorum, especially if you start small like Dr. Hildreth suggests. Perhaps you have a crucial sales meeting tomorrow. Start by thinking through very minor difficulties like traffic making you five minutes late, or spilling a small amount of coffee on yourself. From there, you could progress through slightly worse events like not having brought the presentation, or maybe losing the sale and the client entirely, ultimately arriving at a place where you can fearlessly visualize yourself in serious crises.

Take a moment now and practice this with something non-crucial. Along the way, don’t just think about the difficult events happening, use the visualization to really dig in and ask yourself how you would handle these outcomes. If you identify serious issues that you have trouble envisioning a path through, you can dedicate time and training to improve your skills or minimize the chance of that issue happening.

For example, maybe you’re visualizing a scenario where you did not bring a presentation. What would you say to your potential clients? How would you get your point across without your materials? Is there an earlier version of the presentation you should be prepared to use? Should you email copies to other members of your team ahead of time?

In the ER, we often perform a version of premeditatio malorum to mentally “walk through” a critical procedure before actually performing it. In doing so, we might visualize a complication occurring, and realize that the piece of backup equipment we would need to manage that complication is not in the room. Having identified this issue ahead of time, we can pause before the procedure and ensure the equipment is available if needed.

Like all forms of visualization, premeditatio malorum takes time and practice, but no matter what precisely you visualize, you will be identifying areas you can improve in your training and mindset, and building better systems to support you when times get tough.

“Do not trip over what is behind you.” — Seneca

Photo by Gaelle Marcel on Unsplash

Things will go wrong during an emergency. Equipment will malfunction, IV lines will blow, the patient will have an allergy no one knew about. We will make mistakes putting in a critical access line, misinterpret an X-ray, call out the wrong dose of a drug. When things do go sub-optimally during a crisis, we face a fundamental choice: Either we are swept away by whatever happened, or we hold fast to our mission and figure out a way to take the next step forward.

Unquestionably, our best response during an emergency comes when we can stay focused on the reality at hand and not be diverted by anger or frustration at things outside our control.

This is not easy, especially when the consequences of an event not breaking the way we hope might be the loss of life or limb. It is, however, necessary: If we trip over something behind us, we will struggle to take care of the next patient — a person who absolutely needs us to be at our best.

It is important to emphasize that this quote is not suggesting we ignore bad outcomes or pretend everything is coming up roses all the time. Far from it. The Stoics would be first in line to say that bad things do happen and that it is up to us how we respond to them. We absolutely need to process and learn from mistakes and terrible outcomes, but we do not need to trip over them by wasting energy being angry or hurt.

Reacting to something going wrong during a crisis therefore has two parts to it: First, don’t make it worse and, second, process it productively.

In the first part, if I feel myself starting to trip over something, I try to interrupt the pattern by thinking about this quote. Sometimes I actually say out loud: “Dworkis, do you need to trip over this thing that is behind you? Is tripping over this helpful?” I have yet to find a time when the answer is yes.

In the second part, I can replay the events of the case — either alone mentally or with a partner or a team — and search for pivotal areas where things could have gone differently. Identifying systemic flaws can improve teams and minimize future errors, but it won’t happen if we are too busy being angry about what happened to think it through.

The first step in putting this idea into practice is to recognize when you are actively tripping over something behind you. It is OK if this recognition does not come immediately. Initially it might be late in the workday before you recognize that you are still “hooked” by something your co-worker said first thing in the morning.

When you do realize you have been tripping over something that is behind you, pause and bring some acceptance and kindheartedness to where you are. You tripped over something that is behind you. That’s OK, especially since you are now about to make it better.

Do a few circuits of the tactical breathing exercise above, then say out loud: “I do not trip over something that is behind me.” Saying it out loud helps break the mental pattern — anger, guilt, or whatever you were feeling.

Now, check in with yourself and take a few more breaths. You might find you are ready to start processing what happened, or maybe you’re not quite there. If you do need more time, no problem. You’ve already stopped the cycle from getting worse, and you are in a better place than a few moments prior.

If you are ready to move on, start thinking carefully through what happened and explore what could have gone better. Along the way, be mindful of tripping again as you get closer to understanding what went wrong; just because we know there is a step at the door to our house does not mean we never trip over it.

Things will, of course, keep going wrong, but when we approach them with this form of patient inquiry, we can stop stumbling around unnecessarily and accelerate our learning and growth.

“Death smiles at all of us. All [we] can do is smile back.” — Marcus Aurelius

Photo by Luigi Boccardo on Unsplash

It is easy to be afraid during an emergency. We might be afraid of death and suffering, afraid that we’re not ready for the task at hand, or afraid that if we misstep, our patients will die. These fears are very real — in part because, sometimes, our patients do die — and when we start out as medical students or young doctors, almost everyone freezes (if only for a second) during the first true test of their newfound abilities.

To respond usefully during a crisis, we must train these fears out. Being afraid of death limits our abilities to respond fluidly and creatively to a critical situation. Outside the ER, this is just as true. When we are working through the crucial point in a business deal, or when an unexpected wave sends us hurtling toward a cluster of sharp rocks, spending time being afraid of the outcome siphons away energy and effort needed to address the problem at hand. As the philosopher Alan Watts put it, “No amount of anxiety is going to make any difference to anything that happens.”

The first step in working through this fear is addressing the reality of our situation as mortal beings: We will die. Coming to grips with this can be difficult, especially if we are not used to thinking about mortality and death.

We can start working through this with using the Stoic idea of memento mori. Translated directly as “remember death,” memento mori functions more broadly as a command to remember that we are mortal, that our time here is short, and it is up to us to figure out what to do with it.

The instruction of memento mori is simple. Think about death. Not once or twice but frequently — make thinking about your death a regular part of your life. There is no special technique, just think about life ending. There is a great library of work on Medium about how memento mori works and its positive effects: For example, consider this deeply awesome piece by Arianna Huffington, this one by Ryan Holiday, this one by August Birch, or this one by Ashley Abramson.

You can start practicing memento mori right now: Stop reading and think for a moment about dying.

When you think about your death, what comes up? Are you happy with your life and proud of how you lived it? If you died today, would there be things you wished you could change? If you are having a hard time getting started, sit down and write your own obituary. Start the first few lines like this:

“[your name] died today at the age of [your age] from [some interesting thing to die from]. They spent their life doing [whatever you do], and is survived by [whomever is in your life]. Toward the end of their life, they cared deeply about [whatever you care about].

Usually when I do this exercise, I imagine myself dying heroically, but that is up to you. You might make it all the way through the obituary, or maybe you will find something so interesting and deep right at the beginning that you need to think about that instead. There is no wrong way to do it, other than to pretend that death will not come for you.

One of the key points about memento mori is that it’s not a one-time thing. Once you have thought about your death like this, keep thinking about it. The idea is not to become obsessed with death, but simply to work on eliminating our paralyzing fear of dying. As I have written about before, one of our key tasks in the first moments of an emergency is to accept the reality of what we are facing. Fear slows our acceptance and can prevent clear thinking when it is most needed. Spending time now, before an emergency, thinking about death and dying helps cut down this fear.

Over a long enough time frame, all of us will die. The fundamental choice is to be terrified of this reality, or to choose to smile back at death and do the best we can with whatever time we are given.

“As long as you live, keep learning how to live.” — Seneca

Photo by Annie Spratt on Unsplash

At the end of a long shift, I often ask myself if I made the world a better place today. I might spend a moment or two thinking about it before I move on to the main question: How am I going to do better tomorrow? In or out of the ER, difficult times and emergencies will continue to come our way, so our training and self-improvement must also continue.

Bad shift? Keep training. Good shift? Keep training.

I love this final Stoic quote because it reminds us that we are never finished evolving. As long as we are alive, we are students of life, and our job is to keep learning and practicing how to live. Personally, I find a deep joy in the idea of consciously choosing to be a student of my own life. With this decision, training to bring the absolute best possible version of ourselves to bear during an emergency becomes more than a part of our jobs — it is part of who we are. We keep training because we believe that we need to be better, that there will be people who need us to be better during a crisis.

During my residency training, I posted a quote up on the wall of our ER from the poet and civil rights activist Maya Angelou: “Do the best you can until you know better. Then when you know better, do better.” It served as a daily reminder of our mission: not to try to be perfect, but each day to do the best we could and set up tomorrow to be even better. Now, farther in my career and training the next generation of emergency doctors, it is no less true of a goal.

We cannot save everyone who comes into the ER any more than we can catch every single wave, or win every single contract. If we demand this unobtainable perfection, we divert energy from the people and situations who need us. We also risk burnout, a particularly serious problem among ER doctors.

So, let it go. Let go of the idea that you can achieve perfection during a crisis, let go of the idea that your training will ever be complete, and just keep training. There is no right or wrong way to do this; some people keep journals where they write down lessons learned from every emergency. Others form groups where they talk through what happened in minute detail and try to identify areas for experimentation and improvement. However you choose to start, each day strive to do the best you possibly can with what you have, and work to make improvements for tomorrow.

There is no shortage of difficult situations in which we can practice applying these five Stoic principles. In or out of the ER, friction and crisis are part of all of our lives. Thankfully, as Seneca also said, “A gem cannot be polished without friction, nor a [person] perfected without trials.” I hope these principles help you when the pressure is on. I know they help me.

Better Humans

Better Humans is a collection of the world's most trustworthy writing on human potential and self improvement by coaches, academics, and aggressive self-experimenters. Articles are based on deep personal experience, science, and research. No fluff, book reports, or listicles.

Dan Dworkis, MD PhD

Written by

Emergency Doctor. Applying knowledge under pressure. The Emergency Mind Podcast: www.bit.ly/emindpod || Connect: linktr.ee/emind

Better Humans

Better Humans is a collection of the world's most trustworthy writing on human potential and self improvement by coaches, academics, and aggressive self-experimenters. Articles are based on deep personal experience, science, and research. No fluff, book reports, or listicles.

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