American Association for Physician Leadership

Where Has the Awe in Medicine Gone? Part I

Neil Baum, MD


Nov 7, 2024


Healthcare Administration Leadership & Management Journal


Volume 2, Issue 6, Pages 276-279


https://doi.org/10.55834/halmj.2449384397


Abstract

Do you remember when you started medical school and received your first white coat? That symbol made us feel like real doctors, and all the energy and effort that was spent to reach that ceremony was worth it. How about the first time you were in the labor and delivery room and participated in the birth of a baby? Or how about the first time you conducted a history, performed a physical exam, wrote findings for the proctor, and functioned like a real doctor? Or how about when you were making rounds with the chief resident, and they told you where to put your stethoscope so you might hear the opening snap of mitral stenosis ... and you really did hear it? These were those special moments that made you feel exhilarated and provided you with a sense of awe. This article defines awe and its benefits to healthcare providers.




When I go to one of the doctors’ lounges or to the lunchroom and sit with physicians, mainly middle-aged and older, I often hear them comment that they wouldn’t go into medicine if they had it to do over again or wouldn’t recommend a career in medicine to their children. When I meet with colleagues, I hear doctors complain about the abundance of paperwork and that requesting prior authorization takes eight to ten hours a week of uncompensated time. I ask you, “Where is the awe?”

Awe is difficult to define. Although religious scholars, philosophers, and sociologists have considered awe’s role in religious transformations, aesthetics, and political change, psychologists historically have had only a fleeting interest in the subject. In 2003, psychologists presented a “conceptual approach to awe” in a paper that presents a theoretical proposal for defining, conceptualizing, and studying awe.(1)

The word awe is derived from Old English and Old Norse words expressing “fear and dread, particularly toward a divine being.” The English meaning evolved into “dread mingled with veneration, reverential or respectful fear; and the attitude of profound reverence in the presence of supreme authority.”(2) Ask someone in the United States about their latest awe experience, and you’re likely to hear about a positive experience in nature.

Features of Awe

Awe has two essential central features: perceived vastness and a need for accommodation.

Although many stimuli that elicit awe are, indeed, physically vast, the idea of “vastness” goes beyond size. Vastness refers to anything that is experienced as being more significant than oneself. So, for example, we can perceive a sense of vastness in the face of an open plain or giant redwood tree, but it can also be induced by “social size” — that is, prestige, authority, or fame. Any stimulus that exceeds a person’s normal range of experience can lead to the perception of vastness. Essentially, awe is any stimulus that leads people to feel as if they are part of something larger than themselves.

Accommodation is the process of adjusting to a new experience. Awe can be both terrifying and enlightening. Experiences of awe allow us to question and revise our understanding of the world.

To elicit awe, an experience must involve both perceived vastness and a need for accommodation. There is a difference between awe and surprise. For example, an experience that consists of a demand for accommodation but not vastness would elicit surprise but not awe. Imagine walking into your house and being greeted with a surprise party. You might experience accommodation. This surprise would only elicit the perception of vastness if your party was at Niagara Falls. You might be surprised but not awed.

Evolution of Awe

No one knows why awe evolved. Awe only occurs in humans. Awe may have evolved among our ancient ancestors because it prompted reverence and devotion to powerful leaders and promoted social cohesion. Another theory suggests that awe evolved because it helped people identify safe places to seek shelter, such as environments with large vistas that would have allowed our hunter-gatherer ancestors to see approaching predators or attackers.

Awe’s ability to elicit accommodation also may explain why humans evolved to experience this unique emotion. Experiencing awe may be adaptive because it encourages us to process new information and adjust around this information, helping us navigate our world and increasing our odds of survival. Finally, awe’s ability to make us feel more connected with others and to be more helpful and generous also may have helped ensure our ancestors’ survival and reproductive success.

Types of Experiences That Elicit Awe

Studies have explored the types of situations that can elicit awe. For example, studies have found that natural scenes often elicit awe, that stimuli do not need to be physically large to elicit awe, and that recalling spiritual and religious experiences can evoke feelings of awe.

There are cultural variations in the awe experience. For example, one study found cultural differences in situations that elicit awe. Personal accomplishments more frequently elicited awe among people in the United States (a more individualistic culture) than among people from China (a more collectivist culture).(3)

Who Experiences Awe?

Various factors may make some people more prone to experiencing awe. For example, more extroverted people may have a greater tendency to experience awe, as may people who are more open to new experiences. People who are less comfortable with ambiguity appear to be less likely to experience awe.

Effects of Awe

Feeling awe can lead to physiological, psychological, and social effects. These range from goosebumps (piloerection) to increased generosity and expanded perception of time.

Physiologic Effects

Awe is associated with physiologic effects, including changes in nervous system activity, goosebumps, chills, and possibly reduced inflammation.

Different negative emotions are associated with different responses by the autonomic nervous system, including the sympathetic component, which controls the bodily functions needed for a fight or flight response, and the parasympathetic branch, which controls the rest and gastrointestinal functions characteristic of the absence of acute stress.

When people viewed awe-inspiring images, parasympathetic activity increased, and sympathetic activity decreased. Awe tends to increase respiration rate (a sympathetic nervous system function) and heart rate.

The autonomic nervous system controls another physiologic response tied to awe: goosebumps, or piloerection. People who kept a journal of the times they experienced goosebumps found that the intensity of goosebumps was positively associated with awe. Another study measured goosebumps directly while participants listened to clips of various music or film pieces; it found a significant association between goosebumps and the feeling of being moved or touched.(4)

Difference Between Goosebumps and Cold Shivers

Goosebumps are associated with positive emotional states, whereas chills are related to adverse conditions. Goosebumps are associated with high levels of awe, but chills are not. People experiencing goosebumps feel more connected to others, whereas experiencing chills has the opposite effect. These findings around goosebumps are consistent with evidence suggesting that experiencing awe makes people feel more connected to others.

Although the studies discussed in this section thus far have focused on the immediate physiologic effects of awe, one study found that frequently experiencing wonder over time could potentially have positive long-term health effects.(5) This study probed a possible link between people’s tendency to experience positive emotions and chronic inflammation, which can increase one’s risk of developing various chronic diseases, including diabetes, heart disease, and neurodegenerative disorders (e.g., Alzheimer disease).

Awe was the only emotion associated with decreased levels of interleukin-6 (IL-6), a proinflammatory cytokine and marker of inflammation. Elevated levels of proinflammatory cytokines have been linked to chronic diseases such as cardiovascular disease, diabetes, and depression. A second part of the study found that participants who reported feeling more awe, wonder, and amazement had lower levels of IL-6.(6)

The Small Self

Awe diminishes a person’s sense of self, shifting their focus away from their own concerns and toward those of the group. Accordingly, perhaps the most studied psychological effect associated with awe is the “small self” — the feeling of being small relative to one’s surroundings. In one study, participants who were asked to describe a time when they had observed a beautiful natural scene reported feeling more awe and more strongly reported feelings of being small or insignificant than those who described a time when they had felt pride about a personal accomplishment.(7) In another study, participants who wrote about emotional experiences after viewing a slide show of either 1) spectacular natural scenes; 2) mundane natural scenes; or 3) neutral scenes found that participants who viewed the spectacular scenes reported feeling more awe and smallness than participants in the other two groups.(8)

Another experiment found that staring at towering eucalyptus trees elicited more awe and feelings of the small self than looking up at a tall building, suggesting that physically large stimuli do not universally evoke the small self. These findings indicate that stimuli do not need to evoke only positive feelings of awe, be physically vast, or be natural scenes to create a perception of a diminished self.

Humility

In addition to causing people to perceive themselves as smaller, awe also may make people humble. Gordon, et al.,(9) found that people prone to experiencing awe were rated as humbler by their friends. They also found that people who reported feeling more awe over two weeks also reported feeling humbler.

Furthermore, participants who experienced an awe-inducing vista in person reported more self-diminishment and feelings of humility than participants who viewed a neutral scene. The findings concluded that awe led to self-diminishment, giving rise to humility.

Another study found that people who recalled a spiritual experience reported feeling more awe than people who recalled a humorous memory.(10)

Why might a relationship exist between awe and humility? Both feelings are essential to understanding people’s place in the world. Awe arises as one confronts the vastness and complexity of the world while humility helps individuals gain perspective on their importance and place within it.

Cognitive Accommodation

The need for cognitive accommodation has been proposed as a core element of the awe experience.(2) A few other studies have sought to determine whether experiencing awe leads people to change how they view the world.(7)

Perception of Time

Awe also may expand our perception of time. People induced to feel awe agreed more strongly with statements suggesting that time is plentiful and expansive.(11) Other experiments in this study found that if people who felt awe experienced this expanded perception of time, they were more willing than others to volunteer their time to help others, prefer experiential purchases over material ones, and report greater satisfaction with their lives.(11)

Connectedness

Research suggests that awe helps people feel more connected to other people.(7) Self-esteem may modify the effect of awe on feelings of connection. Specifically, people with lower self-esteem reported less identification with others after exposure to an awe-inspiring video than a neutral one. Still, people with higher self-esteem reported more identification with others than those viewing a neutral condition.(1)

”Mini” Experiences of Awe in Medicine

There are variations in awe; not every experience will be jaw-dropping. I recall giving a presentation on the importance of PSA screening, especially for African-American men and men who have had a family member with prostate cancer. Several months after the program, I received a note from one of the men in the audience. The gentleman told me he went for a PSA test after my lecture. The test result was elevated, and a biopsy confirmed prostate cancer. He subsequently had treatment for localized prostate cancer. His note expressed his appreciation for informing him of the importance of PSA screening, and he felt that the lecture saved his life. For me, that note was a tiny experience of awe. His message motivated me to continue to address other lay audiences.

Bottom Line: Awe is an emotion that makes us feel excitement, energy, and stress reduction. There are many opportunities for awe in medicine, which has been absent for several decades. In the second part of this article, I will discuss how to put awe back into medicine.

References

  1. Allen S. The Science of Awe. White paper. Greater Good Science Center at UC Berkeley; 2018. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Awe_FINAL.pdf .

  2. Keltner D, Haidt J. Approaching awe, a moral, spiritual, and aesthetic emotion. Cogn Emot. 2003;17:297-314. https://doi.org/10.1080/02699930302297

  3. Nomura M, Tsuda A, Rappleye J. How awe works in humanitarian setting in East Asia: cultural differences in describing the experience of awe. In: Chiao JW, ed. Oxford Handbook of Cultural Neuroscience and Global Mental Health. Oxford University Press; 2022: 221-232. https://doi.org/10.1093/oxfordhb/9780190057695.013.32

  4. Benedek M, Kaernbach C. Physiological correlates and emotional specificity of human piloerection. Biol Psychol. 2011;86:320-329. https://doi.org/10.1016/j.biopsycho.2010.12.012

  5. Stellar JE, John-Henderson N, Anderson CL, Gordon AM, McNeil GD, Keltner D. Positive affect and markers of inflammation: discrete positive emotions predict lower levels of inflammatory cytokines. Emotion. 2015;15(2):129. https://doi.org/10.1037/emo0000033

  6. Catibusic SW. Subjective well-being and biomarkers of health: the relationship between subjective well-being, the immune system and hypothalamic-pituitary adrenal axis activation (2017).

  7. Shiota MN, Keltner D, Mossman A. The nature of awe: elicitors, appraisals, and effects on self-concept. Cogn Emot. 2007;21:944-963. https://doi.org/10.1080/02699930600923668

  8. Joye Y, Bolderdijk JW. An exploratory study into the effects of extraordinary nature on emotions, mood, and prosociality. Front Psychol. 2015;5:1577. https://doi.org/10.3389/fpsyg.2014.01577

  9. Gordon AM, Stellar JE, Anderson CL, McNeil GD, Loew D, Keltner D. The dark side of the sublime: distinguishing a threat-based variant of awe. J Pers Soc Psycho. 2017;13: 310-328. https://doi.org/10.1037/pspp0000120

  10. Preston JL, Shin F. Spiritual experiences evoke awe through the small self in both religious and non-religious individuals. Journal of Experimental Social Psychology. 2017;70: 212-221. https://doi.org/10.1016/j.jesp.2016.11.006

  11. Rudd M, Vohs KD, Aaker J. Awe expands people’s perception of time, alters decision making, and enhances well-being. Psychological science. 2012;23:1130-1136. https://doi.org/10.1177/0956797612438731

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