At Induction, a Crash Course in Tonglen

Abstract

Preoperative anxiety is widespread among patients scheduled for surgery, and pharmacologic anxiolysis has become a standard in the preoperative setting. The readily available drugs are effective and consistent with our tendency in modern medicine to treat problems pharmacologically. In addition, while hypnosis and contemplative techniques are emerging in some clinical settings, anesthesiologists are traditionally not educated in nonpharmacological approaches for anxiolysis. As the American Heart Association (AHA) recently put it, “As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person.”1 Compassionately taking care of a patient is at the very core of clinical medicine and has the potential to provide meaningful context and connection, thereby preventing burnout.2 In part due to Daniel Goleman’s milestone publication on emotional intelligence, in which self-reflection and self-regulation are key components,3 mindfulness-based practices have found acceptance in Western cultures. Nowadays, meditation is more and more recognized as alleviating stress and enhancing immunity. As the AHA states, “there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause cardiovascular disease.”1 In addition, compassion, that is, the readiness to understand others and to act to alleviate their negative experiences, has been shown as a strong positive emotion that activates the parasympathetic nervous system and positive feelings.4 My personal spiritual journey began with Vipassana and Metta meditation 2 decades ago in my late twenties. Later, I started to practice Hatha yoga (Table). Thereby, I learned to enrich my contemplative training with Pranayama and Tonglen (Table). In the latter, the trainee is contemplatively sending out compassion and accepting negative realities. The practice is linked to the practitioner’s breathing by imagining inhaling the negative realities and exhaling compassion and is typically visualized with the imagination of colors representing compassion and grayness representing negative mental constructs.5 Notably, this contemplation practice has been shown to significantly increase alpha power amplitudes in the electroencephalogram (EEG), a marker of quiet wakefulness as key in cognition.6 Table. - Contemplative Techniques Vipassana meditation Traditional Asian contemplation technique based on observing your thoughts and emotions as they are, without any judging and consciously letting them disappear Metta meditation Traditional Asian contemplation technique based on sending kindness and selfless love to oneself, close people, and eventually to all living beings in the world Hatha yoga Traditional Indian exercise combining physical exercises and breathing exercises Pranayama Traditional Asian contemplation technique based on conscious control of breath to align body and mind Tonglen Traditional Tibetan contemplation of imagining inhaling the negative realities and exhaling compassion. The practice is typically visualized with the imagination of colors representing compassion and grayness representing negative mental constructs While this practice offers a great opportunity for mindfulness training during one’s daily routine, it can empower the anesthesiologist to compassionately interact with a patient during induction of general anesthesia: on arrival or during preoxygenation, the anesthesiologist instructs the patient to imagine inhaling colors representing great memories, kind thoughts, close friends, or good feelings and exhaling grayness representing stress, anxiety, and worries. At the same time, the anesthesiologist unnoticeably but compassionately exhales positive thoughts and inhales the patient’s negative ones, that is, the classic Tonglen contemplation (Figure).Figure.: Explanatory illustration of compassionate Tonglen practice, eg, during preoxygenation of a patient before the induction of general anesthesia. A, The anesthesiologist connects with the patient by guiding the imagination of inhaling colorful great memories, kind thoughts, or good feelings through the oxygen mask and (B) exhalation of all gray stress, anxiety, and worries. Thereby, the anesthesiologist can contemplatively do the opposite, that is, inhale the patient’s gray stress, anxiety, and worries and exhale colorful positive emotional attractors for the patient.In my personal experience, this simple and brief practice not only unites me mentally with the patient at hand but also calms down the vast majority of patients immediately. They implicitly understand that “I, your anesthesiologist, accept the responsibility for all of you while you are under my care.”