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The science of hope
1 Plays9 months ago
In this episode, Dr. Zanotti discusses the science of hope. He's joined by Dr. Stephen Trzeciak, a physician-scientist, the Edward D. Viner Endowed Chief of Medicine at Cooper University Health Care, and Professor and Chair of Medicine at Cooper Medical School of Rowan University in Camden, New Jersey. Dr. Trzeciak is a practicing intensivist and a clinical researcher with more than 100 publications in the scientific literature. In addition, he is co-author of two excellent books: Wonder Drug: 7 Scientifically Proven Ways That Serving Others Is the Best Medicine for Yourself (2022) and Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference (2019).
Additional resources:
Recovery Expectations and Long-term Prognosis of Patients with Coronary Heart Disease Barefoot JC, et al. JAMA Internal Medicine 2011: https://pubmed.ncbi.nlm.nih.gov/21357800/
Optimism and Rehospitalization After Coronary Artery Bypass Graft Surgery. Scheler MF, et al. JAMA Int Med 1999: https://pubmed.ncbi.nlm.nih.gov/10219928/
The median is not the message. By Jay Gould: https://journalofethics.ama-assn.org/sites/joedb/files/2018-05/mnar1-1301.pdf
Books mentioned in this episode:
Man’s Search for Meaning. By Viktor E. Frankl: https://bit.ly/3SqsNyt
Wonder Drug: 7 Scientifically Proven Ways That Serving Others Is the Best Medicine for Yourself. By Stephen Trzeciak and Anthony Mazzarelli: https://bit.ly/4kiyA5q
Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. By Stephen Trzeciak and Anthony Mazzarelli: https://bit.ly/43ul5IE
Recommended
Transcript
Introduction
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Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
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Sound provides comprehensive critical care programs to hospitals across the country.
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
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And now your host, Dr. Sergio Zanotti.
Celebrating Critical Care Awareness Month
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May is Critical Care Awareness Month.
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It is a time dedicated to recognizing and honoring the contributions of critical care professionals.
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With this in mind, I chose a special topic for today's podcast.
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We will discuss the science of hope.
Guest Introduction: Dr. Steven Treziak
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Our guest is Dr. Steven Treziak, a physician scientist, the Edward Deviner Endowed Chief of Medicine at Cooper University Healthcare and Professor and Chair of Medicine at Cooper Medical School of Bruin University in Camden, New Jersey.
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Dr. Trizek is a practicing intensivist and a clinical researcher with more than 100 publications in the scientific literature.
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In addition, he is the co-author of two excellent books, Wonder Drug, Seven Scientifically Proven Ways That Serving Others Is the Best Medicine for Yourself, and Compassionomics, The Revolutionary Scientific Evidence That Caring Makes a Difference.
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His work has been featured in numerous media outlets, including CNN, NPR, USA Today, The Washington Post, Harvard Business Review, and Freakonomics.
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He is a dear friend and holds two important distinctions in the podcast universe.
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He was the first guest on Critical Matters and with today's episode is the guest with the most episodes on Critical Matters.
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Steve, congratulations and welcome back.
00:01:46
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Thank you so much for the honor, Sergio.
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It's great to be back on the podcast and as always, I'm looking forward to the conversation.
The Role of Hope in Intensive Care
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Well, I've obviously, we've been friends for a long time.
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We've kind of grew through critical care together.
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And I'm always fascinated by your capacity to find topics to research deeply, very rigorously.
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And it seems that you found a new topic that we're going to talk about today.
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And my first question, Steve, is why should intensivists care about the topic of hope?
00:02:20
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So I need to start with a confession, right?
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And it's not easy for me to say, and it's a confession that many of your listeners who are, many of those listeners are probably physicians.
00:02:36
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It's gonna come as a surprise, perhaps even shocking to them.
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But about over 30 years ago now, in the late 1980s, in a moment of youthful indiscretion
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I decided to become a philosophy major.
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Now, I also did all the pre-med courses, so just to be clear, but my philosophy training taught me a lot of things.
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And I need to tell you, I was not the greatest student in philosophy.
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My grades were fine, but I wasn't the kind of student that could
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list all the famous philosophers and their major tenets or beliefs or anything like that.
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And I still can't do that today.
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That was never my aim.
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But what I did learn through my undergraduate training, I learned to gravitate to the big questions.
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And as a result, it's that that gravitating to the big questions has led me to a lot of the things that I've been working on over the last seven years or so.
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It was also my first lesson in hope because I remember sitting down for the MCAT exam and recognizing as I was sitting in that lecture hall, as we did it back in the in those days,
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realizing that there wasn't a great job market for philosophers.
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So my first great experiment in hope was taking that test and realizing I either stick the landing on this exam and I'm a doctor or I am hopelessly unemployed forever.
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But my gravitating to the big questions has led me to asking the question, does hope really matter?
Hope and Compassion in Health and Success
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I mean, years ago, my colleague and co-author, Dr. Anthony Mazzarelli, who's a practicing emergency physician, but he's also co-president and CEO of our health system, we asked the question, does compassion really matter?
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Later in our second book, we asked the question, like, what's the evidence-based way to live your life?
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Is it all about you or should it be directed towards outwardly towards other people and helping and serving?
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And what effects does that have on your health and your longevity and your professional success?
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And now with this new work, we are asking the question, does hope really matter?
00:05:12
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Because hope is something we talk about literally all the time, but we almost never stop to think critically about hope and what it means and what it doesn't mean.
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And years ago in my career, I was studying resuscitation science in the ICU.
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So my colleagues and I, we had...
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NIH grants to study brain injury after cardiac arrest.
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And specifically, we were trying to figure out what was the optimal level of oxygen in the blood that would reduce the risk of permanent neurological disability after resuscitation from cardiac arrest.
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And now I study things like compassion, kindness, and hope.
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And of course, that's a pivot or a change in trajectory.
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But the reason is because
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of this gravitation towards the big questions.
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And with the question, does hope really matter?
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I mean, it either matters or it doesn't matter.
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And if it does matter, when does it matter?
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When does it not matter?
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If it matters, then how much does it matter?
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And what's the effect size?
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In what context does it matter or not matter?
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And what is the responder phenotype?
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So as intensivists, we meet people often on the worst day of their life.
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And as we
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as they come under our care and come into our ICUs, we see that look of fear in their eyes and in their faces and those are their family members and their loved ones.
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But we also remarkably see hope.
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And the question is that Dr. Maz and I are posing in the most recent work is, does hope really matter?
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Or is it just some feeling that is trivial?
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And so,
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The reason why, to get back to your question, why should an intensivist care about hope, is actually there's evidence, Sergio, that we're in the midst of a hopelessness crisis right now.
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And so it's very timely right now, perhaps now more than ever.
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Perfect.
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And I think that, as you mentioned philosophy at the beginning, many of our listeners probably imagine philosophy as an abstract, deep, impractical pursuit.
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But the truth is that the origins of philosophy are really attached to just living a better life and finding a framework to answer big questions.
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So I believe that that is a perfect tool to complement with science, which I know is what you're trying to do to move the needle forward on these questions.
00:07:51
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How would you define hope, Steve?
00:07:55
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So I want to be clear about one thing.
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I don't have any magical thinking.
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So there's no, I don't have any Pollyanna-like beliefs.
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So Pollyanna was this novel from like 100 years ago about a girl who was not only optimistic about everything, but to a degree that was ridiculous and quite frankly, probably annoying to everybody that was around her.
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And I don't have any of that sort of magical thinking.
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I don't believe in rose-colored glasses.
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Those things are not what I'm interested in.
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There is a body of evidence around the science of hope, and that's what I'm interested in.
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So a researcher's definition of hope is this.
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Hope is a belief that
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So it's not a feeling.
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It's not an emotion.
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It's a belief.
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It's the belief that the future will in fact be better than the present.
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And, and this is an important, is an important distinction.
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And you play a role in making it so.
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So hope is a belief that the future will be better than the present and you play a role in making it so.
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So there are emotions involved, of course, in hope.
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We've all experienced that.
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We know it experientially because if you've been feeling hopeless and then all of a sudden you have a glimmer of hope, we all know that that feels good.
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So of course there are emotions associated with it, but it's not an emotion in and of itself.
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It's a belief that
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And importantly, it involves inspired actions because we play a role in making it so.
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So there's a framework that was introduced actually decades ago by a researcher by the name of Rick Snyder, and it's called Hope Theory.
Understanding Hope Theory
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Hope Theory.
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And Hope Theory has three main components.
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One is future casting or goal setting.
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So what is it that you are striving for?
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Is it something positive that you're striving for?
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Or is it something that you're trying a negative outcome that you're trying to avoid?
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So that's the first component.
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The second component is pathways thinking.
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So pathways thinking involves how are we going to get there and how
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there are going to be obstacles.
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So how are we going to navigate around those obstacles when they occur and they will?
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So it's planning and expecting for obstacles and not just having a plan A, but having a plan A, B, C, D, E for when those obstacles come up.
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And the last part is agency or willpower.
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And that's why Snyder called it the will and the ways or the will and the pathways of hope.
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Willpower is
00:11:14
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is our, others have framed it as grit or as in other framings, but it is our ability to stay on that path when that path becomes difficult.
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And the willpower to stay on the path is a little bit, the only critique I would have of Snyder's framework on hope theory is
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is that there is also power in the agency of others.
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And he didn't really write about that back in the day.
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But imagine a patient that comes into your ICU, they don't necessarily have a lot of capacity to influence their outcome.
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but their agency can be that they trust you as the physician or as the nurse or as the therapist and the caregivers and they buy in to the fact that you know what you're doing and you have their best interests at heart and you're going to take good care of them and so they put their trust in you or perhaps their adherence to a treatment regimen the only hole in in snyder's framework for hope theory in my opinion
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is that there's power in the agency of others.
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And so it's not, hope can be a team sport.
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It's not just all about you and what's in your head.
The Crisis of Hopelessness
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And the reason why this is so important now, Sergio, is because there's tons of data that we're in the midst of a hopelessness crisis.
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So Snyder came up with this like 30 years ago, but it's more relevant now than ever.
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And I say this through no
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political lens whatsoever.
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But there is evidence that besides rates of depression and anxiety and despair skyrocketing, particularly among young people, there was a recent CDC report that a staggering, in my opinion, 44% of American high school students report persistent feelings of hopelessness.
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And that's a 40% increase since 2009.
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And over half of college students have felt hopeless at some point in the last year.
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And so I didn't say depressed or sad.
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I said hopeless.
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And that's measured with very well-validated scales.
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And that hopelessness crisis is way beyond mental health because when hope is lost, people disengage from life.
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from other people, from their work, from education, they lose sight of everything and their sense of purpose.
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And those deaths of despair then skyrocket.
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So deaths of despair are deaths by suicide or addiction.
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And what the research shows is that the deaths of despair over the past 20 years
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among men specifically.
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It's been sharply accelerating among women.
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Among men, the acceleration has been so steep and the deaths of despair have risen so sharply over the last 20 years that the incremental increase alone is over 400,000 people, more than the U.S. lost in World War II.
00:14:43
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And so I think that the time is now to start thinking critically about hope and its consequences.
00:14:52
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When you were talking about the definition that researchers apply and what you're considering as you study hope, a couple of things came to mind immediately, Steve.
Balancing Realism and Hope
00:15:04
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Obviously, the importance of avoiding magical thinking and not hoping for specific things, but more of having that unwavering belief that
00:15:17
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that we, the we, right, at healthcare, it's the we, it's the family, the patient, and the caring team, or in the individual case, the I, will be able to figure out things in a way that they can move the needle for a better position of what they are right now, correct?
00:15:35
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And it really made me think of the Stockdale Paradox.
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Are you familiar with that story?
00:15:44
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Well, I'm familiar with it because it was covered, I think, in Good to Great, which is like kind of a classic business text.
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But if I remember correctly, Stockdale was an admiral who was a prisoner of war.
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And what he observed was that the people in the camps that would die in
00:16:10
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compared to survivors, it was the people who said, we're going to be out by Christmas, we're going to be out by Easter, we're going to be out by this milestone or that milestone, even though they had no legitimate reason to believe that that was true.
00:16:24
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And then when their dreams were crushed, when they didn't make it out, that's when they succumb and they didn't survive.
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Whereas the Stockdale paradox is,
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is the belief that you will prevail in the end, but at the same time, having a very honest appraisal and stark awareness of the present circumstances.
00:16:54
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So Stockdale believe, yeah, I don't know when we're going to get out of here, but we're not going to give up.
00:17:00
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And it was that paradoxical thinking that you can have in balance or have a balance between the stark reality and still be hopeful.
00:17:11
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And it was that combination that led people to survive.
00:17:14
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Does that sound right?
00:17:16
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That's perfect.
00:17:16
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Exactly what happened.
00:17:17
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I mean, it's those who face the harsh realities of their captivity without any illusions, but maintain that unwavering faith that they would eventually overcome the ordeal.
00:17:28
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Right.
00:17:28
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And that focused,
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on the agency they had.
00:17:32
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So what are the things that I do control, which is obviously a very stoic kind of approach.
00:17:37
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But the reason why I was also asking about Stockdale is because it leads me to my next question, which how is hope different from optimism?
00:17:49
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So optimism is a really important concept.
00:17:53
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It's distinctly different from hope.
00:17:55
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And again, this is using the researchers definition of hope.
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where we said it's a belief that the future will be present better than the present and that we play a role in making it so.
00:18:07
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Optimism, in contrast, is the belief that things are going to work out, but you have absolutely no idea why or how.
00:18:15
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So there's no agency involved.
00:18:17
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So, for example, optimism is more like just wishful thinking.
00:18:26
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So we use the word hope all the time in speaking.
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I hope it doesn't rain this weekend.
00:18:33
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Well, that's true.
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I hope it doesn't rain this weekend.
00:18:36
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But is that really hope or is that a wish?
00:18:38
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Because I have no capacity whatsoever to influence that.
00:18:43
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So when we use the word hope as a verb, it's very different than when we use the word hope as a noun.
00:18:50
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Right.
00:18:51
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So I hope it doesn't rain this weekend is very different than I have lost hope or I have found hope.
00:19:01
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Completely different meaning.
00:19:03
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And optimism is,
00:19:06
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And I need to acknowledge that much of the research that's been done on the health effects of expectations or beliefs in this domain has used the framing of optimism or used tools that measured optimism.
00:19:20
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And there's tons of evidence that optimism is associated with better health.
00:19:27
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But optimism...
00:19:28
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from a researcher's standpoint is different because there's optimism is more like just wishful thinking over something that you can't possibly really influence.
00:19:41
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There's a concept that I've heard you talk about, Steve, in some recent talks you gave that I think is very important for our patients and families after critical illness and that you tie into your conversations about hope.
Hope's Impact on Health Outcomes
00:19:57
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which is the concept of regoaling.
00:20:00
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Could you kind of weave that into this initial introduction and then we can maybe move to a different area?
00:20:09
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Sure.
00:20:09
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So there was a study in Journal of Critical Care from 2017 in 1,000 survivors from the ICU.
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And what they did is they measured...
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hopelessness, which there are scales to measure that, by the way, and hopelessness may be distinct from hope.
00:20:29
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Maybe they may not be just extremes on a single continuum.
00:20:34
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They may be distinctly different, just like depression is not
00:20:40
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on a single continuum with happiness.
00:20:42
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Like depression is a clinical entity in and of itself.
00:20:45
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Similarly, hopelessness may be a distinct thing from either being high or low on hope.
00:20:54
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But what these researchers did is they measured hopelessness.
00:20:57
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And I might add that many studies that have tied hopelessness to poor clinical outcomes have controlled for
00:21:11
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that hopelessness is actually distinct from depression.
00:21:18
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But in this study, what they found is that after controlling for severity of illness in the ICU and age and comorbid conditions, that hopelessness was an independent predictor of mortality over the subsequent three years.
00:21:34
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And this was after people have already survived the ICU.
00:21:38
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And it was independently associated with a 15% higher odds of death.
00:21:44
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And so the reason why this is important in the ICU is that... Sergio, can you remind me what the original question was?
00:22:05
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I'm really sorry.
00:22:11
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The importance of regoling post-critical illness.
00:22:13
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Regoling.
00:22:14
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Yeah.
00:22:14
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Regoling.
00:22:16
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Sorry.
00:22:17
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When I geek out on medical studies, I get caught up.
00:22:22
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Yeah, regoling.
00:22:23
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So regoling is a...
00:22:31
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is a very important thing.
00:22:34
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Regoling refers to, and this is again from the researcher's standpoint, regoling is when there is no pathway through.
00:22:43
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So a patient might be thinking that they can make it through, they may be able to survive their bad diagnosis.
00:22:54
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Regoling is when all those pathways shut down
00:22:59
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They are no longer possible.
00:23:01
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And regoaling involves radical acceptance.
00:23:05
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And that radical acceptance is that you may, the future that you thought was possible is no longer possible.
00:23:18
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You might have never thought that you were going to be in the circumstances that you are now in.
00:23:25
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This is your new reality.
00:23:27
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However, however, life can still be meaningful and maybe life can still even be great.
00:23:39
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It's just that now you need radical acceptance of your new reality.
00:23:44
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And so re-goaling, which can be very painful for patients and for families and outside of healthcare, for people going through major life circumstances, re-goaling can be very painful.
00:23:57
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But that radical acceptance then shifts one's focus on finding meaning among these new circumstances that perhaps one never thought that they would be in.
00:24:10
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And I guess in a way, this concept is really what might be at play in those studies that evaluate happiness or well-being in lottery winners versus recent paraplegics, and they find that there's no difference.
00:24:26
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And it might be that the people who went through a horrible medical illness accident that led them paraplegic have the ability to regal and find meaning again, right?
00:24:36
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That kind of post-traumatic growth.
00:24:38
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type of phenomenon in their life.
00:24:41
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Is that kind of, there's some overlap there?
00:24:45
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I think so.
00:24:47
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I'm not an expert in research on adjustment to illness, but I think there has to be some element of regulling in the research that you mentioned.
00:24:59
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I mean, it makes sense to me just intuitively.
00:25:02
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And the reason why I was asking, as obviously this is a critical care focused podcast, I often encounter questions about patients' prognosis in terms like, is there any hope, doctor?
00:25:18
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Should we lose hope?
00:25:21
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Along those lines, and I'm always of the belief that
00:25:24
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There's always hope.
00:25:25
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We should always hope.
00:25:26
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But sometimes people need to hope for something different, and that might fall in the regoaling category, right?
00:25:32
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What are we hoping to achieve through our agency together and how we can move the needle to a better place compared to where we are right now?
00:25:40
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And I just find it interesting as you articulate some of these ideas, and I learn from you a little bit more about the science, how...
00:25:49
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certain things kind of fit into what we've been doing for a long time, but we just didn't have maybe the proper lexicon to articulate it in a clear way.
00:26:02
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Sergio, you raise a bunch of important things in what you just said.
00:26:07
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I want to say something about hope in the ICU because I
00:26:13
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When I speak in general about this, I sense that from trainees, I might get a little bit of eye rolling.
00:26:23
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And the reason why is because you don't have to be in our field for very long to experience or to meet people and their patients and their families who have
00:26:38
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an expectation or a hope, perhaps, we could frame it that way, that really doesn't line up with the reality of their situation.
00:26:48
Speaker
And there's this concept of false hope.
00:26:52
Speaker
So false hope is when there is no pathway, there is no way through.
00:26:57
Speaker
And that's what we're regoaling, when regoaling needs to occur.
00:27:01
Speaker
Right?
00:27:03
Speaker
And the example might be someone with a, you know, stage four metastatic diagnosis of some sort where they're thinking that just one more, you know, treatment might, you know, magically cure them or something like that.
00:27:18
Speaker
And that's not, and that's the clinician's experience.
00:27:24
Speaker
And it doesn't take long to have an experience like that.
00:27:28
Speaker
But those of us that have practiced for,
00:27:31
Speaker
longer and have more experience have also experienced the other side of that, where there's a patient where you can tell that they're completely hopeless, but you actually see a way through.
00:27:45
Speaker
And you're thinking to yourself, well, it may be difficult.
00:27:50
Speaker
There may be many obstacles and it may not happen.
00:27:54
Speaker
You may not get a cure out of this, but I see a way through for you, but they're not seeing it for themselves.
00:28:01
Speaker
So it really goes both ways.
00:28:04
Speaker
And that just brings me back to the question, does hope really matter?
00:28:09
Speaker
I mean, it either does or it doesn't.
00:28:11
Speaker
And when it does, when does it and how much does it matter?
00:28:16
Speaker
And so the way I look at it, and I think that there's, this is just my opinion now, what I'm going to share with you.
00:28:23
Speaker
And lots of folks that are listening might disagree, but this is the framing.
00:28:26
Speaker
This is how I look at it.
00:28:29
Speaker
When a patient is expecting an outcome that you think is unlikely, think of the bell curve.
00:28:39
Speaker
There's a bell curve for outcomes.
00:28:41
Speaker
And of course, most curves for outcomes are right skewed.
00:28:48
Speaker
Many of them are right skewed with a long tail to the right.
00:28:53
Speaker
And then you remember there's skewness, but there's also kurtosis.
00:28:56
Speaker
Like how thick is that tail?
00:28:59
Speaker
So let's say a patient comes to the ICU with bad diagnosis.
00:29:02
Speaker
Well, if you look at the median on that, because there's no perfect biological systems often don't follow a perfect bell curve.
00:29:11
Speaker
So it's typically skewed to the right.
00:29:13
Speaker
Maybe the median is, you know, two months of survival or something like that.
00:29:19
Speaker
But we have to acknowledge that there is a right skew to that.
00:29:23
Speaker
And there may be a very long tail.
00:29:25
Speaker
There may even be a thick tail.
00:29:26
Speaker
But the reason why I'm raising this is I try to teach the trainees when they have expectations for an outcome that you think is unlikely, they're not asking you for any magical thinking.
00:29:42
Speaker
What they're asking for is the opportunity to be an outlier on the curve.
00:29:48
Speaker
And if you think of it that way, it's more of a math matter rather than magical beliefs.
00:29:58
Speaker
And some people, I mean, if there's a right curve, somebody does survive much longer.
00:30:04
Speaker
Who's it going to be?
00:30:05
Speaker
Your patient and their family are just asking you for the possibility that they're going to be the person way out on the right side of the curve.
00:30:13
Speaker
And if you think of it that way, because I often see trainees frustrated by
00:30:19
Speaker
a discordance in beliefs or outcome expectations.
00:30:26
Speaker
If you think of it that way, it can be a little bit perhaps easier to deal with.
00:30:34
Speaker
I think it's also, in my mind, easier to get behind their beliefs that really they're just asking to be a statistical outlier and
00:30:42
Speaker
That are my thoughts.
00:30:43
Speaker
What do you think about that, Sergio?
00:30:45
Speaker
And I think it's an interesting way of framing it.
00:30:48
Speaker
And I do believe that in general, we are very nihilistic in the ICU and we have to be very careful with that because you are right.
00:30:56
Speaker
We don't really know if this particular patient could be an outlier, right, or where they would fall.
00:31:05
Speaker
And I think we jumped to negative assumptions too quickly.
00:31:09
Speaker
And that might be just...
00:31:10
Speaker
because we're conditioned by everything that we see.
00:31:13
Speaker
Like you said, the bell curve, the majority of these patients don't do very well.
00:31:17
Speaker
But I do believe that hoping for the right things and framing hope in the context of reality for a patient and for their family probably is something positive that we could all do a little bit better.
00:31:32
Speaker
And I think it's something that I have over the years also changed my way of thinking and started also not only in terms of maybe this goes more in the regoling, Steve, but what we judge as a life worth living.
00:31:48
Speaker
might not be aligned with what a specific patient judges a life worth living, right?
00:31:56
Speaker
They might have a reason that we don't understand, or maybe they have a reason that we don't have right now, but we were in their position, right?
00:32:06
Speaker
And I think you have to be very humble about those end-of-life conversations and how we project to patients.
00:32:14
Speaker
Absolutely.
00:32:15
Speaker
I love what you just said.
00:32:19
Speaker
Once you have enough experience in critical care practice, you're going to be surprised in both directions, right?
00:32:25
Speaker
You're going to have patients that you're very hopeful for, that you think that they're going to make it.
00:32:33
Speaker
they end up with a very poor outcome.
00:32:35
Speaker
And that's very disappointing.
00:32:37
Speaker
And then on the other side of that, there are going to be patients who you think they have no chance of making a functional recovery and then
00:32:45
Speaker
months or years later, you're greeted by somebody who comes back to the ICU to thank everybody.
00:32:50
Speaker
And you're like, who are you?
00:32:52
Speaker
And then you suddenly realize, oh my gosh, that is Mr. or Ms., the person you thought had no chance.
00:32:59
Speaker
And now they're bringing everybody Dunkin' Donuts, right?
00:33:03
Speaker
And you'll be surprised in both directions.
00:33:06
Speaker
So that, it's especially the latter example that makes me
00:33:14
Speaker
There's a quote from, I believe it was Oliver Wendell Holmes, and it was something to the effect of, beware how you take away hope from another human being.
00:33:24
Speaker
You don't have a crystal ball.
00:33:26
Speaker
You have statistics.
00:33:28
Speaker
You've got curves, survival curves, and you've got right skewed curves often.
00:33:36
Speaker
People, somebody's got to be an outlier.
00:33:39
Speaker
So, you know, when your patients and families are just asking you for that opportunity.
00:33:46
Speaker
And when it comes to mind, and I'll put it in the show notes, is that a famous essay by Stephen Jay Gould, The Median's Not the Message, talks exactly about outliers and survival.
00:34:01
Speaker
And again, I think it's a good read for us to also apply that.
00:34:06
Speaker
true statistics to the individual patient, right?
00:34:09
Speaker
We, we, we talk in averages and medians, but the reality is that individuals are not averages.
00:34:15
Speaker
And like you said, you can't, you can't apply population-based statistics to an individual.
00:34:20
Speaker
Yeah.
00:34:21
Speaker
So you can say, if I have a hundred patients, this is what I would expect.
00:34:25
Speaker
But now let's talk about the very specifics for your loved one or for you, if you're the, you know, the patient, um, uh, the median is not the message.
00:34:34
Speaker
I agree.
00:34:35
Speaker
Steve, could you share with us
00:34:39
Speaker
evidence available today that points towards whether hope matters or doesn't matter for patient outcomes.
00:34:47
Speaker
Now, I've seen some of the studies that you have talked about, and there's an important number, but maybe if you could choose some that you think are more robust or more critical, just to share with our audience that there is actually science out there looking at hope and its impact on patient outcomes.
00:35:08
Speaker
Sure.
00:35:09
Speaker
So the most striking, I guess I'd call it my favorite, is a study that was published in Archives of Internal Medicine back in 2011.
00:35:19
Speaker
Archives of Internal Medicine is now JAMA Internal Medicine, but you can find it in archives.
00:35:25
Speaker
And this was a study from Duke University in their cardiovascular clinical trials group.
00:35:33
Speaker
And what they did is they enrolled patients who were undergoing cardiac catheterization for acute coronary syndrome.
00:35:41
Speaker
So the patients didn't necessarily have to have a PCI or a stent or anything like, you know, anything like that.
00:35:46
Speaker
But they clearly had an emergent, potentially life-threatening event needing emergent cardiac catheterization.
00:35:56
Speaker
And after, this was a study of almost 3,000 patients, right?
00:36:01
Speaker
And what they did is they measured recovery expectations, recovery expectations.
00:36:09
Speaker
So that's perhaps a little bit different from hope in the broad sense, because this is now putting it in the context of just suffering a potentially life-threatening cardiovascular emergency.
00:36:21
Speaker
And so the recovery expectation questions were things like, do you believe, and this was after
00:36:29
Speaker
the cardiac cath, presumably in the CCU or something like that.
00:36:34
Speaker
Do you believe you're going to still be able to do all the things that you enjoy in life?
00:36:40
Speaker
Do you believe you're going to be able to go back to work after your heart emergency?
00:36:46
Speaker
Do you believe that you're going to fully recover physically?
00:36:50
Speaker
Do you believe that this is going to affect your family life?
00:36:54
Speaker
So basically recovery expectations, it was a battery of 18 questions.
00:37:00
Speaker
It was, do you think you're going to get your life back is really what it was asking.
00:37:05
Speaker
And the results were striking.
00:37:07
Speaker
And they followed these patients for up to 18 years.
00:37:11
Speaker
And there is a survival curve over time in the study, which is absolutely striking.
00:37:18
Speaker
And Sergio, if you could drop it into the show notes, it would be helpful to people, I think, or at least a reference, so they could go to the publication and check it out.
00:37:32
Speaker
but there's a survival curve over time where it shows those with the greatest recovery expectations, those with the second tier, third quartile, and then the bottom.
00:37:42
Speaker
And there's a very sharp discrimination between the highest recovery expectations and lowest in terms of survival over time.
00:37:54
Speaker
And when they adjusted the analysis for age, comorbid conditions,
00:38:00
Speaker
severity of the coronary artery disease, as evidenced on the cardiac cath, as well as the presence or absence of depression symptoms.
00:38:10
Speaker
What they found is that higher expectation for recovery was independently associated with a 17% lower risk of long-term mortality with depression.
00:38:23
Speaker
as I said, up to 18 years of follow-up.
00:38:26
Speaker
And in terms of mechanism of action, Sergio, I mean, there are many potential ones.
00:38:33
Speaker
And there are certainly ones that are very practical.
00:38:37
Speaker
So people who are more hopeful, practically speaking, are more likely to strictly adhere to treatment recommendations.
00:38:46
Speaker
Right.
00:38:47
Speaker
They're more likely to follow advice or more likely to take their medicine.
00:38:50
Speaker
They're more likely to or less likely to be lost to follow up compared to people who are hopeless, who really kind of give up on all that stuff.
00:38:57
Speaker
So that's a very practical way that hope can affect health outcomes.
00:39:02
Speaker
There are also...
00:39:05
Speaker
physiological effects.
00:39:07
Speaker
So just like we know that loneliness can have very negative effects on one's health, not just their well-being, but their physical health, that's because chronic loneliness is like a chronic stress response that is sustained over time.
00:39:26
Speaker
And that can powerfully affect one's physiology, their risks of atherosclerotic heart disease, for example.
00:39:35
Speaker
Similarly, having sustained positive psychological states, such as hopefulness, has been associated with positive physiological effects.
00:39:51
Speaker
So again, this is sustained over time.
00:39:54
Speaker
It's not like a one and done.
00:39:55
Speaker
It's not like, yeah, we eat our vegetables once and we think we're going to live to be 90.
00:39:59
Speaker
But if sustained over time, if we are hopeful versus being hopeless, there is lower activation of pathways of stress pathways, chronic stress, perhaps lower systemic inflammation.
00:40:17
Speaker
There are some studies to support that as well.
00:40:20
Speaker
So there can be biological effects above and beyond the behavioral effects of just better adherence.
00:40:29
Speaker
So I would say that the Duke study is my favorite, but there are a bunch more that we can talk about as much as you like.
00:40:35
Speaker
And in other areas, other than cardiovascular medicine, I've seen you talk about cancer and mental health.
00:40:45
Speaker
Could you just mention a little bit of what the evidence points in that direction?
00:40:51
Speaker
Sure.
00:40:51
Speaker
What I can tell you is that of the studies, whether it's a framing of optimism in their effects on health or hopelessness in their effects on health, most of the studies have been in the domain of cardiovascular disease.
00:41:15
Speaker
And so that's an important thing.
00:41:19
Speaker
There are, as you mentioned, studies in other domains as well.
00:41:26
Speaker
I should also mention that there's also evidence in stroke, which obviously is part of cardiovascular disease.
00:41:34
Speaker
But there's also evidence on longevity, independent of any specific
00:41:41
Speaker
medical conditions.
00:41:43
Speaker
So just like the Harvard study of adult development has shown that relationships matter in terms of predicting long-term longevity as well as well-being, there's also evidence that being more
00:42:01
Speaker
and most of these studies framed it as optimism, being more optimistic, is independently associated with longer life as well as longer health span.
00:42:13
Speaker
So not just chronological longer life, but also better functional status among elderly persons.
00:42:25
Speaker
And so this is for elderly people as well as for teenagers.
00:42:30
Speaker
So like a Harvard study, for example, of 11,000 teenagers measured their level of hope and then assessed their health 12 years later in adulthood.
00:42:39
Speaker
And after controlling for potential confounders, they found that compared to low hope kids, those with high hope had not only better self-rated health, but fewer depression symptoms, increased happiness, more satisfaction, and
00:42:59
Speaker
with becoming parents themselves.
00:43:02
Speaker
There's also evidence in patients with at risk for cognitive impairment, a University of Michigan study
00:43:20
Speaker
of over 4,000 adults, elderly persons, found that optimism or hope was independently associated with a 48% lower odds of developing cognitive impairment over four years of follow-up.
00:43:36
Speaker
So at both extremes, whether it's teenagers or elderly folks, their optimism has been associated with better health outcomes.
00:43:47
Speaker
So clearly there's evidence suggesting that when hope is present, the outcomes are better than when it's not present.
Nurturing Hope in Critical Care
00:43:56
Speaker
And I'm thinking, OK, that's great news if you're wired for hope.
00:44:00
Speaker
So my next question, Steve, is can hope be learned?
00:44:04
Speaker
Is this nature or can it be nurtured?
00:44:06
Speaker
And if you could tell us a little bit more about that.
00:44:12
Speaker
I love the question.
00:44:13
Speaker
So there are some studies that are in twins, twin studies that show or that point to the fact that there is probably some genetic preponderance to be more optimistic than not.
00:44:31
Speaker
But it's the researchers that have studied this have found that it's probably like maybe one third of one's propensity to
00:44:40
Speaker
to be hopeful or to be optimistic.
00:44:42
Speaker
What that means is that two thirds is not.
00:44:46
Speaker
And so it is potentially learnable
00:44:51
Speaker
And there have been studies to increase recovery expectations among people who are sick.
00:44:59
Speaker
But just I think the most important evidence is probably among young people.
00:45:07
Speaker
So in at-risk youth, so people who are growing up with
00:45:12
Speaker
uh adverse childhood experiences and uh perhaps not only socioeconomic but at risk for um violence and things like that
00:45:24
Speaker
raising hope is possible among at-risk youth and those with higher hope go on to have better academic outcomes as well as mental health outcomes.
00:45:37
Speaker
And so that from, I'm not an expert in at-risk youth, but I've looked at that evidence and that's where it's most striking.
00:45:47
Speaker
And
00:45:48
Speaker
it underscores that hope can in fact be nurtured.
00:45:54
Speaker
And I think that's an important message.
00:45:58
Speaker
So in the context of the ICU, and as we get to the close of our podcast episode today, what is Dr. Tresiak's recommendation for practical advice for raising hope in the ICU?
00:46:13
Speaker
So...
00:46:18
Speaker
The first thing that I think is important is that we need to avoid the therapeutic nihilism that you spoke of earlier.
00:46:31
Speaker
That while certainly many patients are going to have very poor outcomes, we don't have a crystal ball, so to speak, to be able to predict with any great precision at an individual level.
00:46:46
Speaker
And avoiding therapeutic nihilism is not only important for patients and for their families, but for those who practice critical care as well.
00:46:55
Speaker
Yes, we have to have very honest conversations with people, of course.
00:47:01
Speaker
Every time I'm working clinically in the ICU, I'm
00:47:04
Speaker
I'm having those very tough conversations with people, and we need to let them know exactly where they are in terms of the data.
00:47:16
Speaker
But again, we can't apply population-based statistics to an individual because individuals will surprise you.
00:47:24
Speaker
I think that recognition is not only good for patients and for families, but for the staff and the total culture of the ICO.
00:47:34
Speaker
Are there other tips that you could provide in terms of raising hope?
00:47:40
Speaker
So I like to think of hope as a tool in the toolkit, so to speak.
00:47:51
Speaker
And I think that when we speak about raising hope, we have to recognize that
00:48:02
Speaker
hope can in fact be raised.
00:48:04
Speaker
And there's this term learned helplessness that came years ago from Dr. Marty Seligman and others from University of Pennsylvania.
00:48:16
Speaker
What we need to recognize is that, and they've found this recently in the last couple of years, they debunked their own
00:48:26
Speaker
theory of learned helplessness.
00:48:28
Speaker
What they found is that we don't learn helplessness.
00:48:33
Speaker
Helplessness is actually the default.
00:48:36
Speaker
And what we learn is hopefulness.
00:48:38
Speaker
And we learn escape from a bad context, from bad situations.
00:48:47
Speaker
He and his colleague, Dr. Meyer,
00:48:52
Speaker
did neuroscience studies to figure out that it's actually the default response is the freeze part of the flight response
00:49:02
Speaker
or fight or freeze, that is actually the default.
00:49:05
Speaker
And what we learn is escape from circumstances of threat.
00:49:12
Speaker
And so we can, in fact, move the needle.
00:49:15
Speaker
We do learn to be hopeful.
00:49:18
Speaker
And so it can, in fact, be raised.
00:49:22
Speaker
And I just try to remember that every day so I don't get dragged down by therapeutic nihilism myself.
00:49:29
Speaker
And in addition to the therapeutic nihilism that applies to our patients, you mentioned that there's a crisis of hopelessness throughout society.
00:49:41
Speaker
We've also seen post-pandemic an increase in burnout conversations among colleagues.
00:49:50
Speaker
And I think a lot of the bemoaning that I hear is the loss of agency,
00:49:55
Speaker
Yet I believe that one way to raise our hope is to find the places where we do have agency to make a difference.
00:50:03
Speaker
Any thoughts on that, Steve?
00:50:06
Speaker
Yeah, I do have thoughts on that.
00:50:10
Speaker
We can have agency in ways that if our eyes are open to them, we will find them.
00:50:17
Speaker
Just look for little things that you can do for patients and their families that maybe aren't going to
00:50:24
Speaker
dramatically change the outcome for the patient, but they're meaningful to them.
00:50:32
Speaker
And if you do those things, you will find that you can move the needle on their experience in the ICU, their experience in the hospital.
00:50:41
Speaker
And little things matter deeply to patients and families.
00:50:45
Speaker
And when you do those things, you get the deeper relationship that flows from that.
00:50:51
Speaker
And it will transform your experience.
00:50:54
Speaker
So I think looking for little things that matter in major ways to patients and families can transform our own experience and promote resilience and resistance to burnout.
00:51:10
Speaker
I want to respect your time.
00:51:12
Speaker
I know this is also an area of ongoing research for you.
00:51:16
Speaker
We definitely would love to have you back and explore some topics that were untouched today deeper.
00:51:22
Speaker
But as we close, Steve, and being a regular on the podcast, you know, we would like to close with a couple of questions unrelated to the clinical topic.
00:51:30
Speaker
Would that be okay?
00:51:32
Speaker
Sure.
00:51:33
Speaker
So are there any books that have influenced your thoughts on hope and how you are thinking of hope or any books that you have gifted often to other people in the hope of raising their levels of hope?
Finding Purpose and Gratitude
00:51:47
Speaker
I guess that's a double there.
00:51:50
Speaker
Yeah, I think the most hopeful book, in my opinion, is Viktor Frankl's Man's Search for Meaning.
00:52:00
Speaker
And the concept that came from
00:52:03
Speaker
that book was what many later called tragic optimism.
00:52:10
Speaker
So Viktor Frankl was a Holocaust survivor in addition to being a physician.
00:52:15
Speaker
He was a psychiatrist.
00:52:18
Speaker
And tragic optimism is the belief that even in the face of tragedy and suffering, individuals can find meaning and purpose in their life.
00:52:29
Speaker
So Frankl would say,
00:52:32
Speaker
that there is no circumstance that can render life meaningless
00:52:39
Speaker
It's just that when people are under those circumstances, they have to look and search for that meaning.
00:52:46
Speaker
It's a fabulous book.
00:52:47
Speaker
You mentioned gifting.
00:52:49
Speaker
I gifted this to one of my kids recently because I think the text is that important.
00:52:56
Speaker
He and the others that went through the horrors of the camps, I mean, those are very grim circumstances.
00:53:03
Speaker
But the lessons that flow from that book, they've been very helpful to me over the years.
00:53:12
Speaker
And I continue to go back to it again and again.
00:53:15
Speaker
And as you mentioned, this book, a theme that has emerged today that...
00:53:21
Speaker
In retrospect, for me, it's quite obvious, but I don't think I would attach to my conversations of hope before talking with you, Steve, is the concept of agency.
00:53:32
Speaker
And I think Franco also talks a lot about agency.
00:53:36
Speaker
through his ordeal and concentration camps, and how even in situations where you're really basically stripped from everything that makes us human, he still found little opportunities for agency that probably helped him find that meaning.
00:53:53
Speaker
So I think definitely, if you haven't read Man's Search for Meaning, like Steve said, highly, highly recommend it, a very important book that will give you a lot of insight.
00:54:07
Speaker
The second question, Steve, relates to changing your mind.
00:54:11
Speaker
Is there anything that you have changed your mind about over the last couple of years that you could share with us?
00:54:19
Speaker
Yeah, it's something I learned a long time ago in doing critical care, but it's just more salient now than ever before.
00:54:29
Speaker
And that is, you know, if it's one thing I've learned in being an intensivist for 25 years, it's
00:54:36
Speaker
It is that life is fragile.
00:54:39
Speaker
Life is fragile.
00:54:40
Speaker
You learn that very quickly in the ICU, but it takes on more salience later in your life.
00:54:46
Speaker
And as my own parents and my wife's parents get older, it doesn't take very much at all to change everything.
00:55:00
Speaker
You know, one...
00:55:02
Speaker
bad fall or one diagnosis of a neurodegenerative disease and then everything's different and so accordingly what it's done you asked me you know what i've changed my mind about i am um my my great i'm more grateful than i've been in the past because
00:55:25
Speaker
The fact that life is fragile is becoming more and more salient for me through family matters and those experiences.
00:55:31
Speaker
So I'm grateful that I woke up today.
00:55:34
Speaker
I'm grateful that I get to come to work today and work on things, whether I'm working clinically or I'm working as the chair of medicine here at Cooper and I'm helping other physicians take care of people and extend the meaningfulness of this work, of their work.
00:55:53
Speaker
You know, it's, I'm more grateful than I used to be.
00:55:57
Speaker
Let's put it that way.
00:55:58
Speaker
As we close, Steve, is there something you would want every listener, every intensivist listening to know?
00:56:05
Speaker
Could be a thought or a quote or just a fact?
Conclusion: The Power of Hope
00:56:12
Speaker
Yeah, I think...
00:56:15
Speaker
what I would want everybody to know, and I'm still curating all this evidence, and that's what I do as a research nerd.
00:56:23
Speaker
I love to curate evidence, and I really just like to explain things to people.
00:56:28
Speaker
And what this work has taught me is that hope is real.
00:56:35
Speaker
You know, it's not a magical thinking.
00:56:38
Speaker
Hope is real, and that hope matters not just in meaningful ways, but also in measurable ways.
00:56:45
Speaker
And that's not just for the people who are lying in the beds connected to the machines in our ICU.
00:56:51
Speaker
Hope also matters for the people who are taking care of them.
00:56:55
Speaker
And I think we ought to stop thinking about hope as some sort of Pollyanna-type thing.
00:57:08
Speaker
that's disconnected from reality.
00:57:11
Speaker
Hope weaves in and out of our lives every single day.
00:57:14
Speaker
And everybody that's listening to your podcast right now is wrestling with hope in some way.
00:57:21
Speaker
Everybody.
00:57:22
Speaker
Whether it is the hope for something that they wish to happen or the hope to avoid something that they don't want to happen.
00:57:30
Speaker
And, you know, hope is I think it's it's fundamental to like the human condition.
00:57:38
Speaker
And we start we ought to start treating it accordingly and thinking critically about it.
00:57:44
Speaker
So I'll just leave you with that.
00:57:47
Speaker
I think this is a perfect place to stop.
00:57:49
Speaker
I want to thank you, Steve, for once again sharing your expertise and your time with us.
00:57:53
Speaker
I hope to have you back, and I do have agency on that, so I'm sure it will come to fruition.
00:57:59
Speaker
And I really enjoyed thinking about this topic that is...
00:58:05
Speaker
common in our day-to-day lexicon, but maybe has a lot more layers than people imagined.
00:58:13
Speaker
And as you expose, very articulate in a way, has a lot of impact on our patients.
00:58:20
Speaker
So thank you and look forward to our next conversation.
00:58:25
Speaker
The pleasure is all mine, Sergio.
00:58:26
Speaker
Thanks very much.
00:58:29
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:58:33
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:58:39
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:58:43
Speaker
To learn more, visit www.soundphysicians.com.