The power of AWE
Myron Yaster MD and Adam S. Was MD
Until the late 1800s, if one was ill, going to a doctor was a crapshoot…it was as likely you would die from the therapies offered (think blood letting) as from the disease being treated. Going back thousands of years, doctors couldn’t do very much and were often priests who offered sacrifices and prayers to the Gods for cures. Later on, they were magicians and astrologers who looked to the stars to predict a patient’s survival but as far as actual therapies not so much. Since the scientific revolutions of the past 200 years we’ve come a long way in our understanding of the underlying causes of disease and the cures we offer. Except perhaps our own profession of anesthesiology. We still don’t really know how many of the drugs we use actually work…we are getting closer but still don’t really know how vapor anesthetics or drugs like propofol produce the “magic” of anesthesiology.
And I’m using the work “magic” quite deliberately. I still remember my first day as a student on an elective rotation in anesthesiology at the Children’s Hospital of Philadelphia as if it was this morning. I’m pretty sure many of you can too. The awe of sprinkling fairy dust and my patient going from alive to what looked like being dead and then at the end of case sprinkling another fairy dust and the patient returned to life. We do this awe inspiring work every in our practice and often fail to realize just how awesome it is. When I had the privilege of working with students the awe inspiring magic of anesthesiology was what I tried to impress in all of them. Dr. Adam Was of the University of Michigan who is joining us today in his first PAAD review, has had similar experiences with his medical students who are always awe struck when they witness their first cardiac patient undergoing deep hypothermic cardiac arrest.
In today’s PAAD, Berkowitz et al.1 discuss recognizing awe in our daily practice of anesthesia. I would urge all of you to read this relatively short and wonderful article in its entirety. Dr. Sean Barnes of the PAAD’s podcast team will interview Dr. Berkowitz and we will post the interview in the near future so keep your eyes peeled. Further, I would urge the education committee of the Society for Pediatric Anesthesia to invite Dr. Berkowitz to one of our future meetings so he can share many of his thoughts to all of us. But first a word on magic and awe from the great movie, The Princess Bride. Myron Yaster MD
Original article
Berkowitz DE, Sherrer DM, Vetter TR. Recognizing the Awe in Anesthesia. Anesth Analg. 2025 Feb 1;140(2):373-378. doi: 10.1213/ANE.0000000000007050. Epub 2025 Jan 10. PMID: 38728225.
The article by Berkowitz and colleagues begins by wonderfully describing our challenging clinical practice landscape and the potentially transformative power of awe: “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.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.”1
It is beyond the scope of a PAAD to discuss the breadth and depth of this article. Berkowitz draws from the foundational work of Keltner5 to describe awe and draw parallels and connections to the practice of anesthesia. While Keltner categorized the “eight wonders of life” which inspire awe (Figure 1).
Berkowitz highlights that we encounter three of these wonders most commonly in anesthesia: moral beauty, life and death, and epiphany
1. Moral Beauty. Keltner described moral beauty as “witnessing acts of kindness, sharing, courage, wisdom, humility and perseverance by other people.” They also found that “humans are most likely to feel awe when they encounter and are moved by moral beauty.” These acts can be found everyday in a hospital or operating room. I (AW) remember feeling awe-inspired the first time I anesthetized a patient who was undergoing a bone marrow harvest for an unknown and unrelated recipient. Witnessing and appreciating these acts can inspire awe, improve mental and emotional health, and potentially serve as a balm against burnout.
2. Life and Death. In a hospital, every day, one can find people having their first day of life or the last; the worst day of their life or the best. Our (AW) institution does a “clap-out” for patients en route to the OR to receive a transplant, which regularly inspires sweeping emotion. On the opposite side of the same coin, I remember being overcome with awe and grief after finishing my first pediatric organ harvest as a fellow. As Berkowitz puts it, “awe helps us understand the eternal cycle of life and death”.
3. Epiphany. This form of awe is described as “a sudden manifestation of the essential nature of something”. It often makes people feel more connected to the greater whole and lessens the feeling of self, which, in turn, can lead to more prosocial behavior. As clinicians continue to report loneliness and lack of community, this form of awe can be particularly helpful at increasing feelings of connectedness.
How can we use awe in our daily lives and practices? The table below contains some suggestions.
To highlight a few specific examples:
1. Offer Awe Gather-Rounds. In group settings, publicly acknowledge and display stories of individuals embodying moral beauty.
2. Identify or create safe spaces – both physical and emotional – for colleagues to share and process their experiences of birth, life and death.
3. Embrace interrelationships and remind yourself, “I am part of something larger than myself” to encourage epiphany.
4. Consider walking meetings and moving in unison to cultivate collective effervescence.
Lastly, we offer Dr. Berkowitz’s compelling remarks given at his recent annual departmental anesthesiology resident graduation banquet. These are thoughts that we should all hold dear to our hearts:
“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.”1
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Berkowitz DE, Sherrer DM, Vetter TR. Recognizing the Awe in Anesthesia. Anesthesia and analgesia 2025;140(2):373-378. (In eng). DOI: 10.1213/ane.0000000000007050.
2. Mollica RF, Fricchione GL. Mental and physical exhaustion of health-care practitioners. Lancet (London, England) 2021;398(10318):2243-2244. (In eng). DOI: 10.1016/s0140-6736(21)02663-5.
3. Monroy M, Keltner D. Awe as a Pathway to Mental and Physical Health. Perspect Psychol Sci 2023;18(2):309-320. (In eng). DOI: 10.1177/17456916221094856.
4. Allen S. The science of awe. Greater Good Science Center at UC Berkely: The John Templeton Foundation; 2018:1-45.