You have to know how to shudder.

IDO NOT REMEMBER when I first heard that phrase but I do remember the patient who showed me it was true. His cancer had metastasized to his spinal cord leaving him a paraplegic. His pain was controlled with an epidural morphine pump. Lack of visceral metastases kept him here for many months. Ultimately he was able to finish his book and live to see the galley proofs. I would visit him at home. We would talk about his comfort level (“good”), his mood (“I’m coping”), and his writing (“coming along”). Periodically he would shudder. His whole body would shake, including his legs and lower torso below the level of spinal cord damage. My first thought was that he was having a seizure. But no, the conversation went on without interruption. It might be spasticity from the cord damage; no, his arms trembled as much as his legs. One by one I considered and dismissed all the medical explanations I could imagine. I asked him what was happening, what he felt. He was completely aware of everything; he knew his body was shuddering. It didn’t bother him— except to make writing harder. He did not feel afraid. He could not control or stop it, but did not feel out of control. In spite of—or defiance of— his impending death, his paralysis and his unobtainable dreams, he was not afraid, resentful, or depressed. He was simply shuddering. Somewhat after he died I came across an etymological fact. In the Hebrew Testament the root word that was either translated as “fear” or “awe” really meant “to tremble when encountering a force.” How honest that is, to go directly to our response to life without filtering it through our fears or mental constructions of what it might be! Yet, how often can we simply experience life without denying it, filtering it, or attempting to make it fit into our preconceived notions? As physicians we are exposed to the rawness of human suffering daily. It can be as mundane as the limits arthritic knees place on walking or as profound as the implications of a young mother whose life is cut short by breast cancer. How do we respond to those events? Do we tremble in awe at the expression of Nature? Do we distance ourselves from human experience by viewing it as a problem to solve? Do we separate ourselves from our shared human suffering by refusing to experience our own pain? A century ago William Osler wrote the essay “Aequanimitas.”1 He felt that physicians should appear imperturbable even if they could not be unmoved by their patients’ illness. Such a role model persists long after it has become self-defeating. Patients no longer demand it. Physicians can no longer sustain it without injuring the very core of what Osler wanted to promote: the physician himself or herself as the instrument of healing. Equanimity—the ability to be balanced and open regardless of circumstances—remains at the center. The task is not to be dispassionate. Rather it is to experience deep feelings, even passion, without losing one’s center of balance. Balance is difficult to maintain. There are so many things that pull us off balance: the desire to please our patients or the people whose approval we seek; the fear of being blamed; worry about not living up to our own or another’s expectations; the fear of causing harm; the desire to