PRELIMINARY OUTLOOK BY JOSÉ ANDRÉS CALVACHE

While pondering about a way to convey a message of hope, kindness and solidarity to my anesthesiology colleagues and to all the healthcare professionals and workers in Colombia and around the world, who are in the frontlines of the COVID-19 pandemic, I realized - once again- the severe impact it has had on our mental health and our lives. In the history of our generation and probably since 1918, mankind had not experienced the deleterious effect of a pandemic of such magnitude on our lives. A disrupting event of such magnitude invites us to reflect daily.

So, I remembered that we, Colombian anesthesiologists, have a fantastic leader who sets an example for many of us, and who is renowned worldwide. A global leader in innovation and the creation of the future: Professor Alejandro Jadad. He used to speak often about pandemics, but pandemics of health and joy.

I met him during that period in his life. In the early 2000s, when I was a medical student who particularly enjoyed clinical trials and evidence-based medicine, it was impossible not to bump into Alejandro Jadad, in his version 1.0 as an Oxford-trained scientist and clinician, famous in the medical research world of pain medicine, end of life care, anesthesiology, eHealth and methodology of controlled experiments. His views have changed, deeply, since then. In my opinion, he reached the pinnacle of academic-scientific development, crossed their limits, and evolved. He moved forward to version 2.0., a version with an insightful interpretation and understanding of what it means to live a profound, valuable, humanistic, and philosophical life. A vision that invites us to rethink our existence and our everyday life. I believe that this second version is strongly influenced by the first.

His mission is now to allow - enable - people, whether as individuals or as a group, to live healthy and happy lives, full of love and with no regrets, until our last breath, as part of a sustainable planet. Alex has been called a "human Internet", since his innovative research and innovation work are intended to bridge 'the high-touch and the high-tech' by identifying and connecting the best minds, the best knowledge, and the best tools, across traditional boundaries, to create and promote new and better approaches for humans to healing, work, love and learn. His work focuses on the creation of a pandemic of health, by harnessing the creativity motivated by high levels of uncertainty, especially in the presence of existential crises. During the COVID-19 pandemic, he was selected as one of the 20 members of the Global Public Health Leadership Coalition, an independent group of experts assembled by the World Federation of Public Health Associations to tackle the biggest challenges of our time.

In one of his lectures, I heard about his relentless search for a pandemic of joy. Of course, I took his statement lightly, not giving it enough thought - as we usually do because of our hurried lifestyles - to grasp such a complex idea; I was unable to understand its meaning. Living through the COVID-19 pandemic I felt the need to go over that text and video, which at that time awakened my interest and probably the interest of many others.

For many years now, Alejandro Jadad has been a member of the Editorial Committee of our journal and from afar we have felt his support. Who could be better qualified to discuss our current reality, our uncertainty, our fears, and our way of coping and taking care of our mental health and the mental health of our loved ones, rather than discussing -at this time- epidemiology or clinical trials? Let's talk about the topics that should be much more important to us all, and that we keep pushing aside, as we focus on making a living.

This editorial is intended to capture the key topics for a pleasant conversation, a virtual encounter that was organized as a question-and-answer session, and which unfolded as a special co-created intellectual and emotional jazz composition. I expect you to feel part of it, and to join us in what should be an ongoing dialogue as we move into what he calls "the next normal".

QUESTIONS, ANSWERS AND REFLECTIONS

José Andrés: Alejandro, the pandemic has changed the lives of many and confronted us with constant challenge and change. Clinical practice has changed, jobs have changed, universities and their settings have changed and the relationships within our families have changed. How do we deal with these huge and accelerated challenges without feeling that we are losing so much each day?

Alejandro: Perhaps a pandemic was needed for us to give ourselves permission to notice new possibilities to live our lives. To do that, we must be prepared to do something that tends to be hard for us: to push the 'pause button' and to notice what is worth noticing, to feel what is worth feeling, and to use our imagination in a way we tend to neglect because we are so focused on the technical or financial aspects of our professional lives.

I will start with an invitation to acknowledge three scenarios and our role in each of them: one is what could be labeled as "what was normal" - which in most cases we disliked-; the second one, which is often called "the new normal"- what is happening to us, forcing us to think and act differently -, and the third, which is "what will be normal" or the "next normal" - the reality that will emerge after the pandemic. I entice you to believe that it is possible to create the latter, protecting what we considered to be the best of our usual way of doing things, and to build on what we are learning during this critical and surrealistic period of time. It is up to us to believe that we can create our own future. If we don't do it, then others will take this opportunity, likely with different incentives and interests from ours, or even in conflict with the interests of the patients we are trying to serve.

Therefore, I would like to ask a particularly relevant question for anesthesiology, one of the jobs most exposed to the risks of the coronavirus: what if we were to believe, really, that the pandemic is an "existential threat" to our own lives, at every level, from the individual to the species as a whole? What new life options would we dare to envisage to adapt to it, and to thrive?

José Andrés: Our frontline job as anesthesiologists, as healthcare practitioners, involves additional challenges in this adaptation, such as long workdays, with constant stress and the biological hazards inherent to our profession. How can we protect our mental health and the health of those we love, our families for instance?

Alejandro: I believe that our answer should be consistent with the magnitude of the pandemic. There is a Chinese proverb which says: "The best time to plant a tree was 20 years ago. The second best time is now". This may be applicable to our mental health: the best time to strengthen it is now. To do this, more than ever in our history, we must come together and respond as a strong and cohesive body. This is the time when unity truly is strength. If we miss the chance to act as a strong collective, the pandemic could crush us from three different angles: financially, impacting our income and the revenues of the organizations we work for; socially, since we are required to be at the frontend fighting the virus, which paradoxically has stigmatized us in many cases; and emotionally, since we are constantly facing a high risk of becoming infected, dealing with very complex cases under suboptimal conditions, under extreme levels of stress, in addition to the strain this brings about in our personal and family life. The best way to protect our families is by allowing all of us, healthcare practitioners, to understand that our priority is to protect ourselves first. A prerequisite to accomplish this goal is to understand that our risk in the "new normal" is so much higher than for the rest of the people.

As healthcare practitioners we exhibit many unfavorable preexisting conditions. Our suicide rates are higher as compared to the general population and among female doctors, it is twice as high as that of non-medical females in society. Our risk to become addicted to drugs is higher, primarily because we have more access to medications than the rest of the people. Some surveys have reported between 45 to 65% higher levels of anxiety among anesthesiologists, with rising numbers matching the rage of the pandemic.

It is unlikely that we will be able to protect our mental health doing more of the same, which in fact was never enough in the "old normal". We must take advantage of this current crisis to reinvent ourselves boldly, ideally taking into account a new concept of health, which I had the opportunity to facilitate in a global collaboration process that lasted over three years.

This concept is so much different from what the WHO suggested in 1948, which states that a healthy individual is someone in a state of complete physical, mental and social wellbeing, and not merely the absence of disease. This is impossible for practically all human beings. Our approach is totally different, since it considers health as the ability of people - both individually and collectively - to adapt to the unavoidable challenges of life. This is consistent with the theory of evolution that considers adaptability -the capacity to respond and adjust to changing circumstances in order to thrive- as the key element for survival.

In order to survive and ideally come out stronger after the pandemic, we must answer the following questions: What kind of future do we want? How should our "next normal" be, if we could reinvent ourselves?, How can we be more supportive of each other?, What new collaboration models are needed to protect ourselves financially, socially and emotionally? Failure to do so will make us disappear. There are many groups interested in replacing us using robotics, artificial intelligence and more submissive technical staff at lower costs.

José Andrés. Amidst this pandemic, it is unavoidable to learn about so many colleagues who have passed away while doing their job. When we speak about death, even those of us who have to deal with it, we usually refer to it as something distant and talking in the third person. We must be aware that death is a life event and amidst this current situation, it can reach our families; would this teach us to live better and live more? This existential crisis, with so much uncertainty, questions our sense of life and its purpose; would it be possible to slow down, slow down ourselves?

Alejandro. Some people think predominantly in numbers, others in stories, others in patterns, others in scenarios... I think in questions. A question I have usually asked at world, international or national congresses, regardless of the specialty, or even at smaller meetings with colleagues - and it is a question I would like to ask to anyone reading this article - is: Would you like to die like your patients are dying now?

Most likely the answer - which always strikes me because of its consistency - will be similar to the answers given by thousands of colleagues around the world: "No!"

Now that the pandemic has heightened our awareness about how we have neglected the way in which we die, I wonder whether we will be able to give death the attention it deserves, and in particular our own death. What will be required so that death will no longer be an enemy we have to defeat, ignore, or deny at all costs as physicians? How would we like to die? What conditions must be present at the end of our life to consider our death good?

The opportunity I have experienced accompanying more than 500 people to die from the moment they realized that they were dying, has taught me many lessons that may help those reading these lines. One of them is that facing death is the same as facing life; and that to die well, we need to live well until our last breath. Another lesson is that thinking, talking and feeling the presence of death, every day, conscientiously and honestly, could inspire us to make the best of what is left for us, and to focus our minds on what is most valuable: our tranquility. This word deserves close attention, particularly in such a surreal and challenging time.

Tranquility was considered for centuries - particularly by pre-Christian philosophers - as the most precious thing, as the most important ingredient for a good, full life. To accomplish tranquility, one must examine and tackle what fuels our fears, our frustrations and our regrets.

Fear is associated with unpleasant or potentially hazardous situations to come.

In other words, fear comes from the future. For all practical purposes, fear is an emotion we probably share with other animals, since it is associated with an actual, known danger or a very likely threat to our lives. For instance, we fear lacking food or being with someone violent, or contracting a lethal virus while caring for patients. Fear helps us to be creative and to protect ourselves. It must be differentiated from anxiety, which is associated with an unknown, imaginary or poorly understood danger. This includes what we feel when we think about failure, solitude, looking foolish, or disappointing someone we love. Anxiety tends to paralyze us. A couple of questions that may be helpful are: What fears are actually anxiety? What really justifies being fearful in this moment?

Frustration has to do with the present, as it is a feeling of powerlessness or insecurity experienced when we don't achieve what we want or expect from life. The typical reaction to frustration is to attack or to emotionally give up, with sadness and apathy; or, trying even harder to succeed in our endeavor. If we insist on believing that life will give us what we want, as long as we try hard enough, or wish it hard enough, we will be frustrated for the rest of our life. What happens in life depends on many factors that are beyond our control. Being obsessed with the result makes us more vulnerable to frustration. What if our starting point was to expect that what we want is not going to happen? This is different from giving up from the start. What I mean is to make the final result less important and to focus on adjusting our expectations. So, may be if instead of asking: Did I accomplish what I wanted? We rather asked: Did I do my best? Did I enjoy it? In the end, if you succeed in achieving your goal, there will be reason to celebrate; otherwise, we could have enough reasons to celebrate anyway, since we enjoyed trying, ideally learning a lot along the way.

Regret is probably the most important source of unhappiness at the end of life, since it is the sadness, shame or guilt we feel acknowledging that we did something we shouldn't have done, or that we didn't do something we should have done. Since it has to do with actions or omissions, and we make so many decisions over our lifetime, it is practically impossible to avoid feelings of regret. The most frequent, painful and lasting cases have to do with the pain we inflict upon ourselves because of our omissions; not having done what we clearly should have done. I would like to ask our readers: Do you think you have to be more assertive, or take more risks, or spend more time with your loved ones? Do you think you can do something today to avoid piling up regrets? In contrast, regrets due to actions are usually more manageable. They are frequently linked to having purposefully hurt someone close. In these cases, the relevant question is: Can you apologize to someone you hurt? What or who could help you do that?

Finally, I would like to share a mental experiment that has been very helpful to me, to position death as the most powerful incentive to live a tranquil, and ideally, joyful life.

It is often said that we should live each day as if it were our last one, and the expression carpe diem is frequently quoted. This dates back to the Romans and is usually interpreted as "seize the day". Carpe could also be translated as equivalent to "grab", as we do with a ripe and juicy fruit. For this, we could consider "Carpe diem" as an invitation to grab each day and savor it to the fullest.

Buddhism suggests an alternative by inviting us to focus our mind on each instant in the present. This is the foundation of meditation. The challenge to most people is that one day is usually too long and full of distracting challenges, while an instant is too short. A practical approach which has worked for me with regards to living the rest of my days in the best possible way, is inspired in an essay by Nietzsche, prompting us to ask ourselves: If given the chance to repeat our life an infinite number of times, without making any changes, would we accept to do it? The answer in most cases would be, "No, thank you!" Obviously, anyone would accept the offer if they could make some changes in their life experiences, particularly the most unpleasant ones.

The strategy that has proven to be most useful to me, and many of the patients I have had the privilege to accompany, changes Nietzsche's challenge, by pointing it towards the future, rather than the past. In fact, more than pointing to the future, it addresses "the extended present", what stands between what is happening in a particular point in time, and what will happen immediately after. The hypothesis is that practically at any moment in which we are aware in our lives, it is reasonable to think that we will be still alive for the next hour. So, according to this rationale, what if we decided to call each one of those intervals, each following hour, "a life unit"? How could we live each one of those units in such a way as to make it infinitely repeatable? Regardless of the answer, these questions make us realize that simply by changing our perception about the next 60 minutes, we may be able to better appreciate the importance of what we are thinking, feeling, and doing at any given point. As a minimum, these questions allow us to assess our life trajectory and what we could do to maintain or to change its course, one hour at a time.

This probably leads me to the major key of this jazz composition we are co-creating as this conversation evolves, José Andrés: What would it take to give ourselves permission - in anesthesiology, in intensive care and in palliative care - to dream big, to dream at a scale consistent with the magnitude and scope of the pandemic, and hence do our best so that in the "next normal" we will enjoy a healthy and joyfully tranquil life, while enabling others to do the same, as part of a sustainable planet?

How about becoming the best example for all of the healthcare professions - and for society as a whole - of how to make this possible, no matter what?

José Andrés. I have heard a magnificent turnaround; a closing of the cycle or end piece for this jazz cadenza, that yields to a new landscape. Alejandro, thank you so much. It's been fantastic, I heard wonderful and interesting ideas during this interview. As it has happened to me every time I am exposed to your ideas - and fortunately this conversation has been recorded and documented for posterity - your invitation has to be pondered and absorbed slowly. You have touched on transcendental topics for which we seldom have time, and now it depends on us whether to appreciate them in depth, if we reflect on them.

On behalf of the Colombian Journal of Anesthesiology, of the Colombian Society of Anesthesiology, and of all healthcare workers in Colombia, and beyond, and our readers, thank you!

Alejandro. Thank you for the opportunity to share with you one life unit. I hope it was special for you, and for everyone joining us at a different time and place, so as to deem it worth repeating and replaying it over and over again.