As to diseases, make a habit of two things—to help, or at least to do no harm.
(Hippocrates in Epidemics, Book I Chapter XI)

University of Colorado Medical Center Department of Internal Medicine house staff August 1969
Front row includes Drs. Edward Genton, William Robinson, Pieter VandenHoven, 
Gordon Meiklejohn, and Warwick Harvey-Smith
3rd row includes fellow interns Charles F. "Rick" Tuffli, James Prochaska, and Michael
Top row includes Richard "Munch" Cussler

Moving to Denver: The Calm Before the Storm

Why Denver?  The non-professional reasons for our decision to select Denver as our first choice for my internship went something like this.  I had lived in flat sprawling and unzoned Houston for eight years by that point, knew the Texas Medical Center and the Rice campus thoroughly, was pretty tired of the Houston scene (though there was much I had never taken time to explore), and felt I needed a fresh venue.  I had always been intolerant of Texas heat, and had by then concluded that the heat tended to drain my energy and ambition (even though I had lived in it all my life).  At some point while visiting outside of Texas, it also became apparent to me that I felt that I did not fit entirely comfortably into Texas's southern, conservative, and cowboy culture, and that perhaps I might thrive better in a more liberal, more secular, and more diverse environment.  We had seen the grandeur of the Colorado Rockies on many vacations, including a ski trip the previous December.  Becky and I increasingly wanted to pursue our interest in the outdoors and natural environments, including mountain settings, whereas most folks in Houston were forced to retreat to air conditioned interiors during the long hot season.  (Seattleites like to advertise on bumper stickers the fictitious "Seattle Rain Festival, September through May", and Houston might well have its own bumper sticker, "Houston Steam Festival, March through October").  We were sorry to be moving out of state away from our families—certainly we were not trying to distance ourselves from them—but we were living in an increasingly mobile society, and the 1000 mile geographic separation seemed at the time to be a small distance that could be overcome with air travel.  Besides, our families had good feelings about Colorado, and everyone looked forward to an opportunity to visit there more.  And it was not entirely apparent, even to ourselves at the time, that we were moving away from Texas more or less permanently.

Moving to Our New Home:  Soon after my June 6 graduation, Becky and I packed our worldly goods into a U-Haul trailer and towed it behind our new Chevelle, heading north for Denver.  (The experience of pulling a heavy trailer is one I would not want to repeat, as it was not always obvious whether I or the trailer was in charge of determining which lane we were trying to occupy when going downhill in mountainous terrain.)  We soon arrived at the charming little unfurnished two-bedroom house we rented at 1050 Locust Street, the first house we occupied as a couple.  Our landlord was Harvey Meyer, a former school principal and a nice guy.  We paid him $155 per month during our year in Denver.  The red brick house had a pretty front and back yard with detached garage, a soft and gentle bluegrass lawn (so different from the coarse chigger-infested St. Augustine or Bermuda grass of our lawns and esplanades in Texas), and an attractive European birch tree in front (which unfortunately broke in half during a heavy spring snowstorm).  Becky enjoyed tending the established flower beds and used this opportunity to begin her lifelong love of ornamental gardening. The living room seemed large because of an absence of furniture and was where we stored our bikes.  We did most of our living in the knotty pine paneled family room equipped with a cozy fireplace (also our first).  Having little to put on the walls, we rented decorative posters from the library.  Mr. Meyer would come by periodically to tinker on things and kept the place in first class condition.

RMNP:  Before starting my internship orientation on June 20, Becky and I engaged in a whirlwind of outdoor activity, proudly purchasing Raichle hiking boots, day packs, and other fascinating hiking paraphernalia for the first time, excited to be entering the alluring world of mountain hiking.  I recall the pride I felt in acquiring these emblems of a particular outdoor lifestyle—there would be many other outdoor pursuits to come, each with its own special costumes, gear, and mystique.  The higher altitude and cooler temperatures were invigorating to me—the heat and biting flies of Colorado's August were yet to come.  Becky and I spent five or six days hiking and camping in cool and rainy Rocky Mountain National Park (RMNP) and drove the Trail Ridge Road.  On one short high altitude hike off Trail Ridge Road, the Toll Memorial Hike (a name honoring a national parks director Roger Wolcott Toll), we were hit with a sudden snowstorm that created near-whiteout conditions, and we had a hard time finding our way back to the car.  

I returned briefly to Fort Worth, Texas on about June 22 to take the Texas State Board examination.

Internship at the University of Colorado Medical Center

UCMC Internship Reputation and Features:  At the professional level, the internship in Denver at the University of Colorado Medical Center and Affiliated Hospitals (hereafter, the UCMC) had a reputation for excellence.  It included rotations at Colorado General Hospital (CGH), a tertiary care major teaching hospital, and the Denver VA Hospital.  Unlike in some internships, this internship required the interns to write all medical orders on patients being cared for by the house staff.  This provision placed much greater responsibility on the intern's shoulders, but was thought to allow him/her to be maximally involved in the decision making process and thereby to learn the most about patient care.  

Overall, Denver was considered a prime geographic destination as a place to intern, because of the outdoor recreation opportunities, including hiking and world-class downhill skiing, as well as the professional desirability of the program.  Because of its attractiveness, the program was highly competitive and attracted high-caliber candidates.  Thus, Denver seemed to have everything going for it to be our first choice for an internship destination, and I was pleased to have matched with their program.  The pay however was low—$417 gross per month at first, eventually raised retroactively to $500/mo or $6,000 for the 12 months period.  Initially we were to have only one week of vacation, but they eventually relented on this as well, and granted us two weeks for the year.

My Internship Schedule, Supervisors, and Colleagues:  The professional duties of my UCMC straight medicine internship were scheduled to begin Monday June 23 (at which time I was actually in Texas), after an all-too-brief orientation the previous Friday, and continued to June 23 of the following year.  The head of the department of medicine, whom I did not get to know very well, was Dr. Gordon Meiklejohn.  The Associate Dean for Postdoctoral Training Programs, and therefore the head of the internship program, was Dr. Carlton L. Shmock—a warm and encouraging person.  But the faculty person directly supervising the interns was Dr. Edward Genton, a stern and demanding figure, a cardiologist who was the bad cop for the kindly Dr. Shmock.  My chief residents that year were initially Dr. Pieter VandenHoven and later on, Dr. Warwick Harvey-Smith.  The latter was a versatile physician hailing from Australia who had done a fellowship in chest medicine.  (He eventually converted to diagnostic radiology and moved to Seattle when I was already in practice.)  He proved to be one of the most likable and inspiring of the physicians I had the privilege of working closely with during internship.  Some of the first and second year residents that I worked directly under were Burt Golub, Tom Gottlieb, Kent Kreider, Bob Vogel, Steve Schaffner, Steve Wallner, Bill Laughrun, Barry Berns, Dave Kepkay, Paul Steer, Jeff Wooddell, and Richard "Munch" Cussler—but I also got to know Jim Backhaus, Marshall Flam, and Sey Katz.  (They would now be termed R2's and R3's, and the internship year has been renamed the R1 year.)

Rocky Start in the Rockies:  My first rotation was 7 1/2 weeks on the inpatient service of the VA Hospital (VAH), under chief resident VandenHoven.  This rotation threw me abruptly into caring for a ward full of very sick men, averaging about 17 to 22 patients at any one time.  Never before or after in my life or medical career would there be another sustained period when there was such a disparity between the level of responsibility I was expected to assume, and the level of preparation and capability I had attained.  We were on call every third night, so we often worked 36 hours straight every third day.  I still had a great deal to learn in order to become highly efficient and effective in the tasks of doing careful histories and physicals, determining what diagnostic tests, consultations, and treatments to order, and monitoring the results of therapy.  A new and uncomfortable pressure fell on me as well, the relentless need to get patients out of the VAH as quickly as possible, in order to keep the number being cared for from becoming impossibly large and exceeding the capacity of the ward.  I soon encountered an unavoidable conflict between this demand to get patients discharged (at the VAH, these were the ones who had received what was bureaucratically termed "maximal hospital benefit") and the desire on the part of some of these recovered patients, often WWII veterans with a strong sense of entitlement, to stay in the nurturing and comfortable hospital environment as long as possible.  It was a very unpleasant conflict to find oneself at the center of.  One patient, incensed at my efforts to get him discharged (made of course in response to pressure from the system), enlisted the support of his congressman, who called to chastise and dissuade me from doing my perceived duty.  Despite my hard work in medical school, I soon felt overwhelmed by the high responsibility and demands of the workload.  Mistakes could, of course, cause serious consequences for these patients.  I have always suffered from (and probably been a better physician for) a compulsive desire for perfection in my medical actions, a well-developed conscience, and a strong sense of compassion for the problems and suffering of my patients.  The accumulating sleep deprivation, the high stress arising from the high responsibility and consequences of errors, my relative inefficiency and inexperience, combined with a stern, remote, and generally unsympathetic chief resident and faculty supervisor combined to make a situation that became at least for a while increasingly unsustainable.  I came close to going under from the stress, sought counsel, and was granted some minimal degree of very temporary relief.  It was a very difficult time in my life, the last time in my medical career when I really questioned whether I would be able to perform the tasks expected of me as a physician (at least until many years later, when I became ill and unable to continue full-time work).  This trial by fire left me badly singed but certainly caused me to rapidly improve my efficiency, and to focus on keeping on-task and doing for the patients what was absolutely essential.  Despite my desire to improve my knowledge of the vast field of internal medicine, I tended to skip the didactic lectures and teaching sessions given for the benefit of the interns, as I felt I could not spare the time away from the unrelenting patient care workload.  Gradually however, I came up to full steam regarding the needed practical working knowledge: I learned better how to navigate the arcane bureaucracy of the VA system; I started attending the lectures; I achieved a precarious equilibrium in dealing with the conflicting demands of residents, faculty, and patients; and I somehow survived to tell this tale.  The first two months or so of my internship were not the proudest times in my medical career—I merely endured rather than prevailed—but I should not beat myself up too much over my responses to this grueling experience, which undoubtedly could have been designed to be more humane to begin with. (See References for more on reforms regarding house staff workload.)

Doctoring And Coping Skills Improve:  Subsequent 7 1/2 week rotations went better: on the CGH internal medicine ward, the internal medicine Intensive Care Unit (ICU), and the CGH ER (where I worked 24 hours on and 24 hours off).  I subsequently returned to the VAH internal medicine ward, again for 7 1/2 weeks, a reprise in which I found myself substantially better prepared to tackle the job.  I even learned how to deal diplomatically with a resident who exhibited what I termed "malignant enthusiasm" for tasks he delegated to me that he always wanted performed in the middle of the night, even when a good case could be made to save at least some of them for the daylight hours.  The 1970 half of my internship included a rotation on neurology at CGH, yet another stretch on the VAH internal medicine ward, and a final stint on the CGH internal medicine ward.  During the final rotation at CGH, I was especially pleased to work under the first year medicine resident Richard "Munch" Cussler, with whom I had an excellent working relationship.  (Becky and I enjoyed a nice car camping and hiking trip with him to the Collegiate Peaks area.)  He was a bright and outstanding physician with a good sense of humor, and he displayed a genuine warmth toward me and our patients.  Perhaps this kind of human touch should make little difference to a battle-hardened intern, but I was not immune to the manner in which I was handled by residents and others supervising me, and certainly responded better to the warm and supportive approach than to the cool aloof approach.  My chief resident by this time was Dr. Harvey-Smith, also a great guy to work under and a subsequent friend during our radiology days in Seattle.  Overall by this time, the medical team that I was part of seemed to have become exceptionally well-oiled and smoothly functioning, a vast improvement from the inefficient struggles I endured when I started my internship.  (Tip: Avoid getting sick in July or August and ending up in a teaching hospital.)

My Patients and What They Taught Me:  I recall a few of the hospitalized patients I cared for as an intern, and can mention some recollections in a way that does not violate their privacy.  This year was the first opportunity I had to treat American Indians, who funneled into the UCMC from many surrounding states.  One was a likable, stoical, and courageous man with a Native American last name that evoked colorful images of stormy weather.  He had a tumor, multiple myeloma, which was destroying his bones, and he eventually succumbed to it.  A teenage girl assigned to me was in the hospital for her umpteenth time for a chronic incurable condition.  She was attended by her caring and worried parents, who were wary of house staff involvement from past bad experiences.  They were pleased with the sympathetic and caring attention I showed to her, which won them all over, and warmly praised me for the simple act of coming up with Phenergan as a seemingly safe solution for her insomnia.  (Ironically, much later recommendations advise against using this as a pediatric drug, so don't take my old recollections as valid medical advice.)   A middle aged man was in the hospital for yet another of thirty to forty admissions over the years for abdominal pain and a variety of other complaints, leading to a number of surgeries.  I made a major diagnostic coup simply by requesting his old charts for review—all three thick volumes of them (comprising a stack about a foot high).  Leafing through the first volume, I discovered the all-important but buried fact that he had been diagnosed with a hereditary disease, acute intermittent porphyria, on his third or fourth admission.  This diagnosis had inexplicably been "lost to follow-up" on numerous subsequent admissions on the surgery services.  (Lesson: Doctors, scan through all of the old charts for each patient to find buried treasures.)  A pleasant older woman I cared for on the neurology service had been admitted some time earlier with the Guillain-Barré Syndrome, an autoimmune neuropathy occurring typically after an infection and which in her caused near-total body paralysis.  She valiantly hung on with inspiring composure and patience, gradually recovering much of her strength over a prolonged recovery period, and was able to be discharged after about a year in the hospital.  Another patient was a middle-aged man desperately ill with a chronic severe pulmonary condition which caused difficulty breathing.  I cared for him for four to six weeks with his wife looking on as he struggled to get enough air.  Despite our efforts he died, leaving me feeling devastated.  I recall being critiqued at the ensuing morbidity and mortality conference for the choice of drugs that I and my team had given him, though our choices had been discussed with and approved by our attending physicians, and I was left feeling guilty that I might have been partly responsible for his death (a conclusion that I did not believe was correct).  Ironically, I ran into his long-suffering wife on the street a few months later, and found her unexpectedly upbeat and cheerful, as if a great load had been lifted from her shoulders.  This helped me to realize that the consequences of seemingly tragic events are not always quite what one might predict.  Along with many other adverse or suboptimal patient outcomes (which were mostly unavoidable), this incident helped me to acquire a greater degree of Oslerian equanimity and a slightly thicker—though still rather thin—skin regarding the suffering and death of patients under my care.

One of my favorite practitioners at the VAH was a psychiatrist I rarely actually ran into, whose last name might have been Lofgren.  When I had a troubled or problem patient with whom I needed help, he was always available for consultation.  The result of such a consultation was usually a magnificent tome of 10 to 15 pages in which he described the patient's life experiences in more detail than I could have ever possibly gleaned on my own in the time available to me.  His write-ups were warm and sympathetic to the patients.  It was a great way to get to know my own patients better and in the most favorable possible light, and I was glad to have this resource to call upon when needed.

Improving People-Handling Skills:  I learned another important lesson as an intern.  One day I responded to a call for emergency resuscitation, and found myself trying to restore the heartbeat of a patient on the liver transplantation service.  Dr. Thomas Starzl had pioneered the first successful liver transplant at the University of Colorado in 1967, and this was one of his prime liver transplant patients.  I was soon surrounded by capable fellows and house staff, but I soldiered on, assisted primarily by one of the surgical residents.  I disagreed with the surgical resident regarding the recommended frequency of chest compressions versus Ambu bag airway ventilations, and since I had taken responsibility for the procedure, asserted my beliefs rather forcefully during the resuscitation attempt.  The patient regrettably did not recover despite our best efforts, and Dr. Starzl looked on glumly in the background.  A day or two later he called me into his office, leaving me quaking in fear that I had done something wrong.  But he was pleasant, and informed me that he believed I was absolutely right in what I had asserted, but that he just did not like seeing me and the surgical resident "arguing over the body", as he termed it.  This evoked memories of past episodes from high school when I had gotten myself into trouble over excessive zeal in scientific argumentation, and I believe I learned at this point to soften my approach when asserting scientific medical opinions—especially when sensitive patient matters and professional egos were on the line in the heat of battle.

Graduation At Last:  I earned a Certificate from the University of Colorado Medical Center/Colorado General Hospital as Intern in Internal Medicine "with satisfaction and credit" for the period June 23, 1969 through June 22, 1970, signed by the department head Gordon Meiklejohn MD and others.  It was a hard-won piece of paper for which I breathed a great sigh of relief.  Though I had learned a lot, I would not ever wish to repeat this experience.  I was coming to understand all too well the ominous phrase that "medicine is a cruel mistress" (at least for male physicians, perhaps a cruel master for female physicians.)

Future Career Directions:  The internship experience in internal medicine probably crystallized my view that I was not ultimately going to want to be a primary care physician or an internist (that is, an internal medicine specialist).  I interviewed with the chairman of radiology, Dr. Marvin Daves, in the spring and applied in April 1970 for a possible future radiology residency position in the Denver program (which involved at least six hospitals).  I was also beginning the process of applying to other radiology programs which eventually included the University of California at San Francisco, Stanford, and the University of Washington.

Life in Colorado Beyond Internship

Weather:  We enjoyed living in a climate that, unlike Texas, had four distinct seasons—we liked the dry air and lack of humidity, the mid-afternoon summer thunderstorms that would briefly burst forth and then rapidly clear, and the generally sunny conditions and surprisingly pleasant temperatures we encountered even in the winter.

Local Hiking and Touring, Family Visits:  As the first summer progressed, we took every opportunity we could find to return to the mountains and trails, mostly in RMNP, including non-technical climbs of easy peaks such as Specimen Mountain and Gray's Peak (14,200 feet elevation).  We loved the vistas and the bracing mountain air, and we enjoyed studying and identifying the alpine flowers and unfamiliar mountain birds.  This seemed like paradise, a real Rocky Mountain high.  I was as active physically as I could be during this year, more so than I had ever been before—for instance, riding my bike to work every day.  One snowy morning in almost white-out conditions, as I was biking home from 24 hours on the ER, a driver with a snow covered windshield ran a stop sign and plowed into me, totaling my bike.  Fortunately, the slippery conditions allowed me to be pushed out of her way with no significant injury.  When winter arrived, we took up downhill skiing again, gradually improving our parallel skiing after some lessons.  (I envied those who had taken up skiing in childhood—it is easier to learn then because of the low center of gravity, and kids are generally more fearless, having fewer responsibilities and anxieties about the risk and consequences of injury.)  We had several family members visit us that year, including Russ (June 1969), my parents (September 1969), and Becky's parents, both brothers, and grandmother.  At Christmas, Becky's parents and brother David visited and he and his mother tried their hand at downhill skiing at Loveland Valley.  Because my time was very limited, our preferred ski destinations were those closest to Denver—Loveland, Winter Park and Arapahoe Basin—and we did not get to try the perhaps better known resorts further away such as Vail and Aspen.  Coming from the Texas climate and on a tight budget, we did not yet have adequate winter clothing to be really comfortable skiing—that would only come later, in Alaska.

Trips to Utah, Arizona, and Texas:  During my precious two weeks of vacation, we made a nice trip in September to the Grand Canyon, Bryce Canyon, Zion, and Mesa Verde National Parks, as well as two trips to Texas to see our families (at Christmas and in April).  The Grand Canyon was especially impressive, and we made perhaps our longest if most poorly provisioned hike ever on a single day, down the South Kaibab trail to the Phantom Ranch at the bottom and back, 14.6 miles round trip to the Ranch and 4600 feet elevation drop to the Colorado River.  We bought some pop and rented bathing suits at the Phantom Ranch, greatly enjoyed cooling off in their pool.  Though it was fiercely hot at the bottom, it rained heavily on the last 5 miles of the return with near-constant lightning—our final mile in fact was illuminated only by lightning as we returned in darkness without other lighting available.  We learned several important lessons regarding preparedness on this trip, as we carried inadequate clothing, not nearly enough water, and no flashlight.  We collapsed into our sleeping bags, ignoring our wet and blistered feet, and by the next morning, the ruptured blister on my heel had become infected.  I developed rapidly progressing fever and ascending lymphangitis, and we drove around 100 miles trying to find a doctor who could prescribe an antibiotic.  (Lesson: Prevent and properly tend to blisters promptly, especially if they are broken, and carry antibiotics if doing arduous hiking away from medical facilities.)  Other than this episode and a wrenched knee skiing, I managed to stay in robust health during this year.

Becky's Work and Graduate Studies:  While living in Denver, Becky explored the possibility of getting a master's degree in French, and began taking some of the prerequisite 400 level courses at Denver University in the mornings (these involved French poetry and drama).  She also took an afternoon job at the University of Colorado Medical Center by working in one of the virology labs, earning about $2,700 for the 12-month period.  Altogether, our 1969 gross income was about $7,600, the last year in which we had to scrape by living, as we thought, close to the poverty level.  (Admittedly this is an exaggeration—the Census Bureau says the official poverty threshold for a couple was about $2,600 in 1970.) 

Other Leisure Activities:  Although I did not find much time for tennis as an intern, Becky took up the sport in Denver for the first time in earnest, and took lessons from a family friend, Doo Barry.  We did not eat out much that year, and we spent what little funds we had left over on outdoor recreation.  The only taste treat I can recall is savoring the root beer floats at the A-1 stand in Estes Park on returning from our hikes in RMNP.  

This was also not a year for partaking of urban culture—in fact we pretty much avoided the downtown Denver cultural scene altogether.  However, we did visit the Denver Museum of Natural History (now called the Denver Museum of Nature & Science), a destination I fondly recalled from childhood visits.  The few movies we saw that year probably included the innovative M*A*S*H (1970), which portrayed a very different image of doctors at work than the sanitized versions we were used to seeing in movies, at once refreshingly candid and somewhat shocking in its depiction of irreverent surgeons working under duress. 

Politics:  My internship occurred during the Nixon regime (1969 – 1974), and I continued to ignore politics.

Richard and Loraine Gonzalez with Becky near Evergreen Colorado August 1969

Loraine Gonzalez and Russ on their birthday 
December 1966

Richard and Loraine Gonzalez:  Our family friends and guardian angels, the Gonzalez's, had bought property to build a home in the mountains near Evergreen (a town 26 miles west of Denver), and had us out there to visit.  They had given me a generous check for medical school graduation, and recalling their love of music and how they had exposed me to several musical genres, I used this money to purchase in July our first stereo system—including a Garrard turntable, Kenwood receiver, Sony tape deck, and probably Advent speakers.  At last we had the electronic gear needed to allow us to enjoy classical music with greater fidelity.  One of my residents had a large record collection acquired in New York, and we exchanged our various records freely.  We were terribly saddened to learn in April 1970 of Loraine Gonzalez's untimely death from a bus accident in London.

Becky with Freude
December 1969

Dog Freude:  We acquired our first "child" in Denver in November, an incredibly cute black and tan dachshund puppy we named Freude.  (This name derived not from Sigmund, but the German for "joy", as in Schiller's Ode to Joy—An Die Freude—used in Beethoven's Ninth Symphony).  Becky would come home from school for lunch, and let Freude out of her enclosure to teach her some of the many tricks she learned: chase her tail, sit, lie down, jump over a stick, etc.  She learned how to sit up to beg on her own.  We took her along when we tried snowshoeing in the spring in RMNP, and though she was dragging bottom on the snow, she seemed to enjoy the outing.  She pretty much displaced our last guinea pig Piggy as the dominant pet in our lives—we finally gave Piggy away to a pupil Becky was tutoring in French.  (Freude, sadly now in doggie heaven, was the only dog we have owned as a couple—we have often thought we should get another but have resisted.) 

Indian Health Service:  I continued to work during this year on the possibility of serving in the Public Health Service in Anchorage in lieu of military service.  Although I no longer have the correspondence related to this effort, which as previously discussed began as far back as 1965 or 1966, I received final orders dated May 14, 1970, ordering me to begin active duty on July 1, 1970 at the Alaska Native Medical Center in Anchorage, Alaska.  We were very pleased with this turn of events.

References and Notes

(1)  House Staff Workload:  In contrast to my experience as an intern, the University of Washington Department of Medicine, like many other medical training programs across the country, was trying (when I first wrote this in 2005) to comply with the ACGME (Accreditation Council for Graduate Medical Education) standard.  This organization set more humane and tolerable maximal hours of work allowed for house staff: a maximum of 80 hours per week; 1 day (24 hours) out of 7 off from work entirely; 10 free hours provided after duty periods and call; on call every 3rd night maximally; and on-site duties not exceeding 24 consecutive hours of patient care and 30 hours total including didactic activities.  How closely these guidelines were and are actually observed at the UW is unclear to me, but it was commendable that such an effort was being made at all, and I am grateful that my physician daughter Wendy received the benefit of this more enlightened approach during her residency years.
(2) Equanimity:  The great Canadian physician and educator Sir William Osler advocated the acquisition by physicians of aequanimitas (equanimity), a kind of even-mindedness, a concerned but detached awareness, an imperturbability that allows composure and competence (and thus the most effective functioning) in the face of patient suffering and tragic outcomes.  As he stated in his essay Aequanimitas, "Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness...  It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients."  Equanimity is distinct from but is sometimes misinterpreted as callousness or indifference to suffering. This topic is nicely discussed in an article by Dr. Charles Bryan appearing in Baylor University Medical Center Proceedings, October 1999;12:277 – 284.

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