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James C. Harris, MD; Catherine D. DeAngelis, MD, MPH

JAMA. 2008;300(24):2919-2920.

The holiday season is traditionally a time for hopefulness as the new year begins. With the promise of a new administration in Washington, there is a renewed sense of optimism for health care reform and hope for better health care for all in the United States. In this Editorial, we start today by reflecting on the essence of personal health care that is based on the depth of the relationship between patient and physician so eloquently described by Peabody: "The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal."¹ Personal care begins with establishing a sense of hope for the patient and seeking to maintain that sense throughout the course of treatment. For patients, that means a hopeful prognosis; a promise that something can be done for their illness; that they will be actively involved in their treatment; or knowledge that hospice care may provide solace for their last days if their illness is terminal.

Hope begins with sincere emotional engagement with a physician who addresses the patient's fears. The human nervous system has evolved to allow for hope. With hope, sleep is restorative, easing daytime fears as emotion is modulated while dreaming,² allowing for waking more refreshed and alert to the challenges of a new day.

The physician's warm reassuring facial expression is a product of the evolution of the family unit and facilitates hopefulness.^3-5 Social engagement is elicited on the most basic level when a physician asks a patient to breathe slowly and relax as the physician speaks to the patient with quiet gentle prosody to facilitate objective listening.³ Listening, the patient spontaneously orients to the face of the physician who seeks to engage the patient by looking into his or her face and eyes. Meaningful social encounter slows the heart, regularizes breathing, and primes the mind to listen. When fully engaged, a patient feels safe. That sense of comfort helps explain why the effect of one person on another is so potent. It also may account for elements of the placebo effect,^6-7 a real physiologic response linked to reward centers in the brain, immune functioning,⁸ and possibly to the release of restorative hormones such as oxytocin.⁹ The psychological experience is that of hopefulness achieved by the balancing of mistrust and trust.¹⁰

Often a patient comes to a physician with a sense of disquiet and dis-ease, not knowing what to expect but hoping to be restored, while fearing the worst. Anxiety is distracting to a patient and makes it difficult for him or her to listen to what a physician has said or is saying. Worse still is despair, when a patient gives up hope completely and shuts down emotionally. How can a physician reassure a patient who is so distressed and ensure that the patient leaves with the expectation that something can be done and is hopeful about his or her condition? To illustrate the importance of this reassurance, Engel¹¹ described the course of a patient in an emergency department who had a first myocardial infarction that progressed to cardiac arrest during the medical evaluation. After recovery the patient reported having felt helpless, angry, and impotent about his medical care because of the impersonal way he had been treated prior to the cardiac arrest.

Engel had earlier proposed that in an interview a physician should look for signs of hopelessness. The hopelessness gesture that he so eloquently described¹² is recognized in the midst of the interview or examination when the patient sighs and reaches out toward the examiner. This reaching out is followed by dropping the arms in resignation and flattening of the facial expression when it goes unrecognized. Like a child who reaches to be picked up and, being ignored by the parent, turns away and begins to cry, the adult too seeks support; but in the adult, reaching out for emotional support is more subtle. A physician should be alert for the hopelessness gesture and consider it a clinical sign and an opportunity to reestablish hope, attend to the patient's disquiet, and console him or her before moving on to the next step of the interview or examination. Modern medical practice intent on completing the electronic medical record or getting to the physical examination risks sacrificing personal care when too much attention is directed to data collection and too little to the patient.

To sustain hope following an encounter with a very sick patient, a physician should consider it an obligation to convene a support group of family, friends, and community members. A confiding relationship with a spouse, close family friend, community member, or physician is a potent force for a patient dealing with an illness and for sustaining hope. A close confiding relationship may reduce rates of rehospitalization after a myocardial infarction.^13-14 Confiding relationships have been reported to be critical aids in preventing relapse in depression^15-17 and some preliminary evidence from a small case series suggests that close relationships might be beneficial in relapse in breast cancer.¹⁸ Prospective studies of the impact of close and confiding relationships on health outcomes are needed, but it is clear that a confiding relationship necessarily activates the social brain and facilitates the physiology of hope.

During this season of hope, physicians should remember that an encounter with a patient should leave the patient emotionally more able to deal with his or her illness. With a deeper understanding of the science of care, physicians will increasingly realize that a meaningful patient-physician encounter leaves each patient better able to adhere to a treatment plan. Most importantly, no patient should ever leave a visit with a physician without a sense of hope.

AUTHOR INFORMATION

Disclosure: Dr Harris and Dr DeAngelis are married to each other.

Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.

Author Affiliations: Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Harris); and Editor in Chief, JAMA (Dr DeAngelis).

REFERENCES
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