Historically, physicians have been tasked with looking after their patients' physical health, diagnosing disease, applying treatments, or healing injuries. As medicine has evolved, so has the idea of what it meant to be “healthy.”
“Health and well-being are not the same thing, but they are closely related to each other,” said William Dale, MD, PhD, chief of the section of geriatrics and palliative medicine at the University of Chicago. “As doctors we think of health in terms of disease—does a patient have this disease or that disease?—but well-being encompasses a lot more than just physical health alone.”
In 1946, the World Health Organization defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Dr. Dale and colleagues applied this definition in a study published on May 15 by Proceedings of the National Academy of Sciences.
They sought to create a comprehensive model of health that measured multiple health domains, including medical, physical, psychological, functional, and sensory measures, and compared it with a medical model that focused only on diseases. Using the medical model, two-thirds of the older U.S. population was considered to be generally healthy, but using the comprehensive model, one-half of this “healthy” population was reclassified as less healthy and was considered to have significant vulnerabilities that could affect the chances of death or incapacitation within the next 5 years.
Social and economic indicators have also been found to affect health outcomes. A project in St. Louis, “For the Sake of All,” found a strong link between such factors as education and neighborhood and disease, disability, and death in African-American communities. For example, ZIP codes only a few miles away from each other had an 18-year difference in life expectancy, with residents in poorer areas lacking in healthy food options, safe outdoor spaces, and access to medical care. To help change these disparities, the project investigators recommended systemic fixes, such as investment in education and mental health awareness and treatment.
How to assess
The Robert Wood Johnson Foundation Commission to Build a Healthier America has recommended expanding the definition of vital signs to include not only things like heart rate, blood pressure, and temperature but also key factors that influence health like employment, education, and housing. However, Dr. Dale noted that the health care system is still not well-equipped for assessing a patient's overall well-being, so internists often need to forge their own path.
Rebecca J. Kurth, MD, FACP, an internist in New York City, focuses on 4 domains: diet, exercise, sleep, and mood. Are patients getting 150 minutes of aerobic exercise a week? Are they getting 3 meals a day? Are they within a calorie amount appropriate for their height, weight, gender, and age? Are they getting 7 hours of sleep? Do they feel safe in bed? Do they feel down or depressed? Do they do activities that give them pleasure?
“I use basic, open-ended questions and try to make patients feel safe,” Dr. Kurth said. “If a patient feels safe, they are more likely to be open and give information.”
Although her practice does use screening forms, especially for things like depression, Dr. Kurth said she has found in her 20 years of practice that patients may be less likely to put information about well-being on a form because they feel that certain things, for example, admitting that they have had thoughts of hurting themselves, can be embarrassing.
Dr. Dale agreed. “Especially given the current time restraints, assessments of well-being are often not done formally with a standard questionnaire but are done by talking with a patient and getting an open-ended history,” he said.
Dr. Dale typically starts visits by asking patients to rate their health as excellent, very good, good, fair, or poor and will ask follow-up questions based on the response. In his experience, patients are honest, but their responses can be limited by their ability to accurately assess themselves.
“I have been in clinic with an older patient and asked them if they are able to do housework, and they respond, ‘Yes!’” Dr. Dale said. “Meanwhile a family member or spouse at the appointment with them is shaking their head side to side, signaling a silent ‘No!’. Sometimes older patients do not recognize how much help they are getting from others or do not realize that they are finding ways to compensate for things they can no longer do.”
Patients may also feel a social pressure to say that everything is OK, Dr. Dale added. He recommended asking patients questions that are specific and allowing them to open up. Instead of asking patients how they are feeling, ask how they feel that day compared with how they usually feel.
In contrast, Jason Q. Purnell, PhD, MPH, assistant professor at Washington University in St. Louis and the lead investigator on the “For the Sake of All” project, does not believe these assessments are entirely intuitive for physicians. Instead, physicians should take advantage of the variety of standardized well-being assessments that are available, he said.
For example, the CDC's National Health Interview Survey (NHIS) uses a Quality of Well-being scale, which measures general health and well-being over the previous 3 days, and asks questions related to satisfaction with emotional and social support and whether participants felt happy in the past 30 days, Dr. Purnell said. He also mentioned several questionnaires to screen for depression, including the 9-item Patient Health Questionnaire or the 21-item Beck Depression Inventory.
In addition, Health Leads, a nonprofit organization based in Boston, recently released a screening toolkit (available free online) to help clinicians assess patients' unmet social needs. The toolkit takes a patient-centered, multiquestion approach to screening that is based on well-researched, clinically validated guidelines from the Institute of Medicine, CMS, CDC, and the Agency for Healthcare Research and Quality, according to Rocco Perla, EdD, president of Health Leads.
The toolkit defines social need domains that are essential (food insecurity, housing instability, and transportation) or optional (child care, employment, and education) and provides a sample screening tool that can be tailored to each practice's patient population. Sample questions include, “Are you worried that in the next 2 months you may not have stable housing?” and “Are you afraid you might be hurt in your apartment building or house?”
“While providers collect an immense amount of patient data every day, when it comes to social needs—which we know impact both outcomes and cost—many are flying blind and don't know where to start,” Dr. Perla said. “Our goal is to help move the health system towards standards for successful social needs screening, give providers a reliable starting point, and spark discussion around standards in social needs interventions.”
Assessing well-being is not the only challenge facing internists. It can be difficult to know how to help a patient once a problem is identified, Dr. Dale admitted.
“If you find these problems, you have to have something you can do about it,” he said. “I try not to unearth too many problems that I do not have adequate follow-up available for addressing.”
This dilemma is likely very common, Dr. Purnell said. “Problems related to well-being are often outside the scope of a provider's practice and expertise. Even if they know about some of these challenges, they might not be equipped or have the right information to help the patient.”
Clinicians who are actively screening for issues related to well-being need to have a structured plan in place, Dr. Purnell said. They should have a set of relationships within the community that they are able to use for referring patients, and, ideally, facilitate a “warm handoff” by introducing the patient and the community-based service provider personally.
Dr. Dale said that he familiarizes himself with community services available to patients and noted that in some cases an online search can find patients help in the area where they live, rather than referring them somewhere within the medical center, where a long commute might discourage them from following up.
In addition to its screening toolkit and other similar free resources, Health Leads offers fee-based training programs, consulting support, and a social needs technology platform to health care organizations or physician practices to help them address patients' basic resource needs by establishing and integrating a successful social needs intervention, Dr. Perla said.
“A growing number of clinicians and health systems are recognizing that unless they address patient social needs directly, they simply can't practice patient-centered and equitable care,” he noted.
Often the first step to helping a patient might be as simple as acknowledging the problem, Dr. Kurth said.
“You can then begin to brainstorm with the patient about how the problem can be fixed or improved,” she said. “The first part of treatment involves acknowledging and discussing what is going on.”
Dr. Purnell said that physicians should be aware of the challenges patients face that affect mental and physical health but cannot be expected to expand the scope of their practice to deal with all of these issues.
“A full complement of tools for well-being would include mental health professionals, social workers, community health works, and more,” Dr. Purnell said. “The pressing issue right now is how do we change the model of medical care so that it is more integrated. And we are working on teams to address these issues.”
An important first step toward this type of change, Dr. Purnell said, is for physicians to play a large role in advocating for changes at the systemic level to make it easier for patients to support their own well-being.
“The medical community must use its considerable influence to change the conversation,” he said.