The National Institutes of Health (NIH) has put itself firmly on record as being deeply concerned about our national epidemic of stress at the individual, organizational and societal levels. NIH’s National Center for Complementary and Integrative Health (NCCIH) broadcast on September 7th its annual Stephen E. Straus Distinguished Lecture in the Science of Complementary Therapies. The lecture was titled A Nation Under Pressure: The Public Health Consequences of Stress in America.



The American Psychological Association (APA) recently documented a worrisome increase in stress in the U.S. population (Stress in America Uncontrolled stress can cause or worsen anxiety, depression, PTSD and a wide range of clinical conditions affecting every organ system. Medical students, residents and practicing physicians experience higher levels of stress than their age-matched counterparts at all levels of medical training....



Of all the sciences, medicine uniquely combines all domains of the human condition-biological, cognitive, emotional, environmental, interpersonal and transpersonal. The more we learn about the benefits of the interpersonal and transpersonal dimensions of health, disease and medical practice, the more we seek to populate medical schools with well-rounded students and humanize medical training and the healthcare workplace.


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The word “doctor” is derived from the Latin, docco, which means “to teach.” Our health care system is incorporating more health and wellness education addressing the whole person- physical, mental, emotional, social, environment and spiritual. And like any good teacher, physicians are more effective as teachers and healers if they are living the healthy lifestyle they are prescribing. As complementary approaches to health gain increasing evidence and societal acceptability, physicians are helping their patients integrate conventional biomedicine with safe and effective lifestyle approaches- and also using these approaches themselves.

The HOPE Note

Jonas developed the HOPE note to complement the SOAP note (Subjective, Objective, Assessment and Plan) as a clinical assessment and documentation tool in patients with chronic conditions- transforming the clinical encounter from one focused solely on disease treatment to one that emphasizes self-care and a whole person perspective, integrating evidence- based complementary approaches with conventional biomedicine. The HOPE note has 4 domains. Answers to these questions can help doctors and patients cooperatively develop strategies and plans to implement healthy lifestyle changes.

The HOPE note has 4 domains. Answers to these questions can help doctors and patients cooperatively develop strategies and plans to implement healthy lifestyle changes.

  1. Mental and Spiritual: Chronic stress-related symptoms often result from living our lives out of touch with our deepest values. Assess patients’ life goals, desires, beliefs, meaning, purpose and values with questions like “Why do you get up in the morning? What is your purpose in life? What matters?” (rather than “What is the matter?”).
  2. Social and Emotional: Group support protects health. Explore patients’ social connections and relationships with family, friends, communities and colleagues.
  3. Lifestyle and Behavioral: Ask patients how they spend their day. Lifestyle and behavior can create health or disease. But sustainably changing behavior must be connected to what is possible and most meaningful to the patient.
  4. Physical Environment: What are your home and neighborhood like? What is your work environment like and how do you get there? Do you get out in nature? These aspects of a patient’s life often determine how much opportunity they have for adopting healthy lifestyles, the course of their chronic conditions and even their length of life.

Relationship Centered Care

Relationships are the very heart of medicine, disease management and patient education. As doctor and teacher, our unique humanness is part of the ‘medicine’ we administer or prescribe. Our commitment to our own physical, mental, emotional, interpersonal and spiritual well-being is the foundation for the quality of care and the quality of caring we deliver.

Let’s assess ourselves using the HOPE note and then inquisitively and empathically use it to assess our patients. They will appreciate your interest in their lives outside the exam room. They are more likely to adhere to a care plan you co-create with them. And your experience of the practice of medicine will help you maintain your own health and well-being.


Wayne Jonas MD is clinical professor of family medicine, Georgetown University, retired Lt. Colonel United States Army Medical Corps and a complementary medicine researcher. He previously served as Director of the Office of Alternative Medicine at NIH, which is now called the National Center for Complementary and Integrative Health. He has recently proposed the HOPE note (Healing Oriented Practices and Environments) as a clinical tool to help physicians add integrative health care to a routine office visit.

Social determinants of health

The conditions in which people are born, grow, live, work and age are increasingly recognized as assets or barriers to living a healthy life. These conditions include socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Our use of the HOPE note can reveal unexpected information about our patients that can dramatically affect our perception of their health-related challenges as well as their resources. We may see more clearly into the reasons they fail to adhere to our treatment plans. We may also be inspired by their ability to simply survive under adverse circumstances.

The patient who has the disease

Over 100 years ago, William Osler’s The Principles and Practice of Medicine contained the often-quoted, “It is much more important to know what sort of a patient has a disease than to know what kind of a disease a patient has.” Jonas’ HOPE note helps physicians know more


about who their patient is and provide better disease prevention and management, specifically integrating safe and effective complementary approaches with conventional medicine.

The imperative of chronic disease management

Chronic conditions are a growing concern as the aging population and lifestyle factors combine to increase treatment costs and overall health care utilization. More than half of the U.S. population have at least one chronic condition, such as hypertension, diabetes, obesity, heart disease, hyperlipidemia, chronic back pain, anxiety, depression and arthritis. Risk factors for these so-called “diseases of affluence” include personal lifestyles and societal conditions such as poverty and the physical environment of one’s home, work, school and health care facility. These conditions can be helped by health education and lifestyle approaches including physical activity, health- promoting nutrition, emotional well-being and complementary mind-body approaches such as massage therapy, skilled relaxation, imagery, journaling, meditation, yoga therapy, social support, restful sleep and mindfulness- based stress reduction.


Dr Patterson chairs the Lexington Medical

Senator Alvarado earned his bachelor's degree in biology from Loma Linda University (California) in 1990, and then went on to receive his Doctorate in Medicine in 1994. He completed his medical residency in Internal Medicine and Pediatrics at the University of Kentucky in 1998. Society's Physician Wellness Commission and is certified in Physician Coaching. He is on the family practice faculty UK College of Medicine and teaches nationally for Saybrook School of Integrative Medicine and Health Sciences (San Francisco) and the Center for Mind Body Medicine (Washington, DC). After 30 years in private family practice in Irvine KY, he now operates the Mind Body Studio in Lexington, where he offers integrative mind-body medicine consultations specializing in mindfulness-based approaches to stress-related chronic conditions and burnout prevention for helping professionals. He can be reached through his website at