Recognizing the Awe in Anesthesia

What is the value of preserving and strengthening this sense of awe and wonder, this recognition of something beyond the boundaries of human existence?... I am sure there is something much deeper, something lasting and significant. Those who dwell as scientist or laymen among the beauties and mysteries of the earth are never alone or weary of life. ——From The Sense of Wonder1 by Rachel Carson (1907–1964), marine biologist, conservationist, and writer In the intense, demanding world of contemporary medicine, health care professionals are confronted with challenges that can lead to physical, emotional, and mental exhaustion. The prevalence of burnout among medical practitioners is now alarming, with a detrimental impact on both individual well-being and patient care.2 A growing body of research suggests that the experience of awe holds significant potential as a simple, implementable strategy to improve physical, emotional, and mental well-being, promote humility, and enhance social connection and thereby teamwork (Figure 1).3,4 The aim of this commentary article was to create awareness of the intersection of "awe" and medicine—with a particular connection to our specialty of anesthesiology—shedding light on the potential benefits that awe-inspiring experiences and interventions can offer.Figure 1.: Model for awe as a pathway to mental and physical health (adapted from Monroy and Keltner).3Drawing primarily from the framework of Keltner,5 we first delve into the concept of awe, to provide a theoretical foundation. We explore ways in which awe can be understood within the medical domain. We consider the potential of awe to enhance human connections, its role in appreciating not only medical breakthroughs but also daily medical practice. We offer an overview of how awe can be integrated into one's medical practice to counteract burnout and promote well-being. Along the way, we will broadly review empirical evidence from existing modalities that have utilized awe. By examining the outcomes and lessons learned from these modalities, we can glean pragmatic insights for adopting pragmatic, awe-based techniques at the individual level, as well as implementing concrete, awe-based interventions within health care organizations and institutions (Table). Table. - Examples of Pragmatic, Awe-Based Techniques at the Individual Level and Concrete, Awe-Based Interventions Within Health Care Organizations and Institutions Awe-inspiring category of life experiences Individual level Organizational level Moral beauty Take note of, be inspired by, and emulate others' acts of courage, kindness, strength, and overcoming in your workplace Offer Awe Gather-Rounds: Publicly acknowledge, highlight, and elevate individual stories of colleagues overcoming obstacles and making a difference in a patient's care Collective effervescence Move in unison by walking with others: while taking an Awe Walk, tap into your childlike sense of wonder and go somewhere new Organize a program that encourages colleagues to find a walking partner and provides paid time to take regular walks together Nature Spend 5 min alone each day outside, walking slowly or sitting quietly: seeing, hearing, smelling, perhaps touching and tasting, the world around you Recognize the human need for Wild Awe by creating places in which the beauty of natural world can be easily accessed by colleagues Music Listen each day, with attention and without any distraction, to a short piece of your favorite musicalgenre or artist Promote colleagues partaking in brief, early morning, midday, or late afternoon performances by local artists across musical genres Visual design Explore the people and places around you by partaking in a visual art, thus discovering the wonders and horrors of life, as well as the sacred geometries in its structures Implement a visual arts program in which creative works of colleagues are prominently displayed on a rotating basis, with a posted short artist biography and description or backstory of each piece Spirituality and religion Seek and find sources of reverence and mystical awe, within yourself and in the everyday company of others in the workplace Provide colleagues with the opportunity and the means to transform their ordinary and extraordinary experiences into images, descriptions, stories, and beliefs about the Divine Life and death Celebrate birth and life, yet bear witness to the dying, be open to suffering and show kindness, and accept not knowing the answers Afford colleagues a safe place and the support to share and to process their sacred experiences of birth, life, and death: the human cycle Epiphany Embrace interrelationships and interdependence: "I am part of something larger than myself" Sustain a corporate culture that openly values the intrinsic worth and contribution of every colleague AWE: DEFINITION AND UNDERPINNINGS Keltner defines awe: "Awe is the feeling of being in the presence of something vast that transcends your current understanding of the world."5 Our personally experiencing such awe seems ineffable—something beyond words—yet for centuries, this has not stopped humans from capturing and sharing their stories of awe: to make sense of the sublime. In doing so, "our individual self gives way to the boundary-dissolving sense of being part of something much larger."5 Applying the tenets of qualitative research, Keltner analyzed, thematically coded, and classified 2600 personal narratives from people in 26 countries and across 20 languages.5,6 The resulting taxonomy, their so-called eight wonders of life,5 categorizes life experiences that most commonly had led people around the world to feel awe (Figure 2): moral beauty, collective effervescence, nature, music, visual design, spirituality and religion, life and death, epiphany.Figure 2.: The "eight wonders of life"—categories of life experiences most commonly leading people around the world to feel awe.5The Practice, Mediators, and Elicitors of Awe At a level railroad or railway crossing, vehicle drivers are advised: "Stop, Look, and Listen." Such heightened situational awareness—together with intentional curiosity and open-mindedness—apply when seeking to experience awe. Awe is marked by a distinct neurophysiological profile: elevated vagal tone, reduced sympathetic arousal, increased oxytocin release, and reduced inflammation—processes that benefit mental and physical health (Figure 1).3 Trait positive affect was associated with lower levels of the proinflammatory cytokine interleukin-6 (IL-6).7 Dispositional joy, contentment, pride, and awe each negatively predicted levels of IL-6; however, awe was the strongest predictor.7 Functional magnetic resonance imaging (fMRI) indicates that experiencing awe is accompanied by decreased activation of brain areas considered part of the default mode network (DMN)—a network of brain regions primarily implicated in self-referential processing. This DMN deactivation on fMRI is aligned with subjective self-report measures, as participants perceived their individual self to be smaller.8 Several studies have empirically explored the various experiences that elicit awe and have identified that certain types of stimuli and events appear to be more common awe elicitors than others.4,5 Likely because of its inherent vastness, immersing one's self in nature is a particularly prominent elicitor of awe. Partaking in various forms of music, dance, or art can be a strong elicitor of awe. Recalling spiritual experiences can elicit awe in both religious and nonreligious people.4,5 By understanding these different dimensions and triggers of awe, we can begin to conceptualize how awe can be harnessed in the context of medicine and health care. For the sake of brevity and clarity, we have chosen to focus here on the relevance and applicability of awe in the practice of anesthesia arising from (a) moral beauty, (b) life and death, and (c) epiphany. THE AWE FROM MORAL BEAUTY IN ANESTHESIA Keltner and colleagues observed that humans are most likely to feel awe when they encounter and are moved by moral beauty.6 Moral beauty refers to witnessing and being awe-inspired by acts of kindness, sharing, courage, wisdom, humility, and perseverance demonstrated by other people.5 More than 95% of the moral beauty that generated awe in their worldwide cohort was in response to actions other people took on behalf of others.5 There has been considerable recent interest in the development, maintenance, manifestation, and benefit of prosocial, other-oriented behaviors.9 Prosocial behavior is any behavior that is intended to benefit another person or persons, and those that are meant to protect or to further the welfare of others.9 A number of empirical studies have reported the positive impact of witnessing others' courage, kindness, strength, and resilience.9 These personal encounters of prosocial behavior resulted in observers feeling more inspired and optimistic, more integrated in their immediate community, and more apt to hear and to heed a calling to become a better person—by imitating others' witnessed acts of courage, kindness, strength, and resilience.5 At its essence, pursuing and practicing medicine are resplendent with moral beauty and prosocial behaviors: abundant with courage, kindness, strength, and resilience. W. H. Auden (1907–1973), opined in his compilation, A Certain World: A Commonplace Book, under the entry for Medicine, that in order to be a good doctor a man must also have a good character, that is to say, whatever weaknesses and foibles he may have, he must love his fellow human beings in the concrete and desire their good before his own. A doctor, like a politician, who loves other men only in the abstract or regards them simply as a source of income can, however clever, do nothing but harm.10 In many respects, like surgery, the practice of anesthesia is a solo pursuit; however, unlike the patient's surgeon, their anesthesiologist remains anonymous. Anesthesiologists have also been relegated to a commodity within many health care ecosystems.11 Herein lie the challenges of creating a sense of community, greater purpose, and shared awe among anesthesiologists. In a 1989 piece in The New York Times, Rosenthal, then an internal medicine resident at New York Hospital-Cornell Medical Center, observed: The field of anesthesia has undergone a major transformation, and anesthesiologists have become the unsung heroes of the operating room. Quietly, they have developed a host of innovations—from safer general anesthesia to effective regional techniques—that are dramatically changing the surgical experience. Rosenthal further shared: It has always struck me as odd that patients will deify their surgeons but be unable to name their anesthesiologists. In the operating room, while the surgeon focuses on your appendix or gall bladder, the anesthesiologist is the guardian of your general well-being.12 As practicing anesthesiologists, we ought to pause more often to witness our colleagues' quiet courage, kindness, strength, and resilience—and to embrace its moral beauty and our attendant awe. This awe can serve as a pathway to better mental and physical health, and hence an antidote to professional burnout (Figure 1).3 Indeed, recent data on learning from excellence shows that prosocial behaviors such as kindness, generosity, and compassion are frequently cited as not only contributing to improved patient care but also as directly impacting the well-being of colleagues.13 Intentionally encountering such prosocial behavior can also promote greater prosocial behavior by us all in the anesthesiology community, thereby ameliorating the recent, demoralizing commoditization of anesthesiology. THE AWE FROM EPIPHANY IN ANESTHESIA Epiphany is "a usually sudden manifestation or perception of the essential nature or meaning of something; an intuitive grasp of reality through something (such as an event) usually simple and striking; an illuminating discovery, realization, or disclosure."14 Keltner posits: What is the substance and structure of awe's epiphany? Its big idea? What form of self-knowledge do we gain in experiences of awe? In our studies and the stories of awe we have encountered, people most reliably say something like: "I am part of something larger than myself."5 Coming to this awe-based epiphany or realization can result in a healthy diminished sense of self (perceived self-importance), which is often accompanied by feelings of increased connectedness with other people.15 Experiencing epiphany-based awe often prompts people to focus less on themselves—an effect known as "the small self"—and to feel more as if they are part of a larger whole.4 When thinking in this more systems-based way, we perceive and endorse patterns of human interdependence—and more frequently exhibit mutually beneficial prosocial behavior.16 Workplace burnout has been recognized to be the result of not only physical, mental, and emotional exhaustion, but also lack of connection and associated loneliness. Psychological studies have found that regularly experiencing awe can give people the vitally needed sense that they have more available time, increase feelings of connectedness with other people, increase critical thinking, increase positive mood and well-being, and decrease materialism.4 A 2019 essay (whose title was a nod to Harry Nilsson) paints a very sobering picture of the multifactorial basis and multidimensional adverse effects of the intrinsic social isolation versus social connectedness among anesthesiologists, across their career and practice setting continuum.17 As practicing anesthesiologists, we ought to pause more often to share our personal experiences of epiphany-based awe with our workplace colleagues—our workplace comrades in arms. We will all benefit, as this form of awe can also serve as a pathway to better mental and physical health, and hence an antidote to professional burnout (Figure 1).3 AWE FROM LIFE AND DEATH IN ANESTHESIA Our profession is often placed in life-and-death situations, for we are there when a newborn arrives into this world and when a patient leaves us. Awe helps us understand the eternal cycle of life and death—from extraordinary, courageous childbirth to bearing witness to, displaying compassion in the face of suffering, yet not knowing what is dying. As his brother was lying in his bed at home, dying of cancer, surrounded by his devoted family, Keltner recounts: "Watching Rolf pass, I felt small. Quiet. Humble. Pure. The boundaries that separated me from the outside world faded. I felt surrounded by something vast and warm. My mind was open, curious, aware, wondering."5 Parker Palmer, American author, educator, and activist, similarly observes: What I know for sure is this: We come from mystery and we return to mystery. I arrived here with no bad memories of wherever I'd come from, so I have no good reason to fear the place to which I'll return. And I know this, too: Standing closer to the reality of death awakens my awe at the gift of life.18 AWE FOSTERS WONDER AND THE VITAL ROLE OF WONDER Keltner suggests: Wonder, the mental state of openness, questioning, and curiosity, and embracing mystery, arises out of experiences of awe. In our studies, people who find more everyday awe show evidence of living with wonder. They are open to new ideas. To what is unknown…To seeking new knowledge…To the strengths and virtues of other people…It should not surprise that people who feel even five minutes a day of everyday awe are more curious about…new scientific discoveries…They feel more comfortable with mysteries, with that which cannot be explained.5 Awe fosters wonder (Figure 3). Hence, without a source of awe, there can be no wonder. Without awe and wonder, there can be no epiphany. Without epiphany, there can be no personal, professional, or scientific discovery and growth. Returning to Carson:Figure 3.: Awe and wonder foster personal, professional, or scientific discovery and growth. (Image created using generative artificial intelligence Adobe Firefly, Adobe, San Jose, CA. Note: Firefly is trained on hundreds of millions of Adobe Stock images, openly licensed content, and public domain content where copyright has expired.)If I had influence with the good fairy who is supposed to preside over the christening of all children, I should ask that her gift to each child in the world be a sense of wonder so indestructible that it would last throughout life, as an unfailing antidote against the boredom and disenchantment of later years, the sterile preoccupation with things that are artificial, the alienation from the sources of our strength.1 A SALIENT, TANGIBLE EXAMPLE OF RECOGNIZING THE AWE IN ANESTHESIA Keltner poses the question: "What is an experience of awe that you have had, when you encountered a vast mystery that transcends your understanding of the world?"5 One of us (D. E. B.) reflected and composed these remarks for his recent annual departmental anesthesiology resident graduation banquet: Have you thought deeply about what we really do as an anesthesiologist? Have you considered the profound impact that we have on the lives of patients that present to us at the most vulnerable moment in their lives? Every day we engage in our profession, we enter an operating room, connect the induction agent—propofol to the intravenous stopcock—and upon depressing the syringe plunger, induce a near-death coma in our patients, characterized by profound changes in the electrical activity of their brain and making them insensible to any surgical assault. Next, we take control of the most basic and fundamental physiologic functions—so fundamental that they are evolutionary conserved in brain regions of all vertebrates! We paralyze the muscle of the body inhibiting all motion and making spontaneous breathing impossible. We use sophisticated breathing devices to maintain ventilation and allow life-sustaining oxygen to diffuse. We next isolate the cardiovascular system from its normal feedback control mechanism, by administering specific small molecules, drugs that control blood pressure and contractile function of the heart. We are not piloting planes. We are piloting our patients. We insert needles next to nerves under the guidance of devices that create images with sound waves transmitted through tissue, and are then reflected back at a rates dependent on their density. We dissect the human anatomy with invisible sound rather than scalpels. We inhibit the firing of these nerves with drugs that render the areas that they innervate, completely insensitive to pain, so much so that we can cut the area with a scalpel in a wide-awake patient without them offering us so much as a blink. And then sensation returns to normal hours later. We are the conductors and coordinators sustaining organ function during heart surgical procedures, some in which the body is cooled to numbing temperatures at which point, pumps are ceased and patients left in a state of suspended animation—that space between life and death. And then they are warmed again and brought back to life, only to awaken a few hours later as if having only been on a mysterious adventure. What we do can only be described as AWE inspiring. We have the awesome privilege of taking care of our patients, imagining the trust that they place in us to return them to consciousness in the state in which they entered the process and is some ways even healthier. The skeptic might say: But what is the big deal, we do this routinely? What's the fuss that this Berkowitz guy is making? It is precisely because we have transformed this awesome process into an ultra-safe routine journey, through intense and unrelenting research, and device development and practice, that makes it all the more marvelous! So my message to you amazingly talented, superbly trained, empathetic and kind residents is simple: When you feel like your work is becoming mundane, boring or uninspiring, think less about your material pursuits. I can assure you, you will certainly have those. Think more of the AWE and wonder in what we do. It will keep you engaged, curious, happy. It will enhance your connections with your teams and create greater optimism, joy and creativity in your work. Continue to find wonder in the world around you. It will keep your relationships and connections with your family and friends more satisfying, and enhance your overall wellness. For those who are leaving us here, remember your friends, colleagues, mentors and teachers who have guided you through this transformative period in your life. And most importantly keep in touch. CONCLUSIONS Implementing tangible, awe-based interventions within health care organizations and institutions (Table), can foster resilience, compassion, and a renewed sense of purpose among all health care professionals. Through our present commentary, we seek to shed light on the transformative potential of awe in anesthesia, and its capacity to combat burnout and to enhance well-being among anesthesiologists. By integrating the principles of awe into our daily professional lives, we can pave the way for more compassionate, resilient, and inspired anesthesiologists, working together in a healthier perioperative ecosystem. We can all realize the powerful impact of this simple practice. We wholeheartedly agree with Keltner when he suggests: "If you have a spare moment, you might think of an awe story of your own."5 E DISCLOSURES Name: Dan E. Berkowitz, MB, BCh. Contribution: This author helped in writing and reviewing the article. Name: D. Matthew Sherrer, MD, MBA. Contribution: This author helped in writing and reviewing the article. Name: Thomas R. Vetter, MD, MPH, MFA. Contribution: This author helped in writing and reviewing the article. This manuscript was handled by: Charles Emala, MS, MD.