I think many GPs with some experience recognise that a major problem in medical practice is not always the medical problem in itself. It is the subjective side of the matter, the patient’s ideas, and possibilities of handling the situation of illness, disease, and functional impairment that are the challenges. None of this was focused on in my medical training and continuous medical education. However, there is now a solid mass of research emphasising the importance of the patient’s subjective side of the matter. Paying attention to the patient’s own assessment of health is important not only as a sign of interest and empathy; it can also be crucial in assessing prognosis, guide consultations to important questions, and guide efforts in handling diseases. All these are lessons learned from research on self-rated health. GPs can confidently use and adopt this research in clinical encounters and clinical research.
WHY?
Outcomes
Outcomes such as mortality, cardiovascular disease, stroke, lung disease, arthritis, functional impairment, depression, and developing diabetes type 2 and its prognosis are associated to self-rated health.1–3
Better than doctors’ ratings
Self-rated health is a better predictor of future health (good health assessed as no symptoms of disease or minimal impairment if symptoms present) than doctors’ ratings.4 It also adds information beyond a doctor’s ordinary clinical evaluation.1,5
Comprehensive
There are innumerable factors affecting patients’ health. Self-rated health is a comprehensive way to assess the patient’s situation.1 Self-rated health can guide doctors and their patients in the search for contributing causes of bad health. Are there disease problems, psychological illness, anxiety, bad economy, violence at home, or other causes at hand? Recently, in an article in the BJGP, self-rated health was proposed as an instrument in screening for cardiovascular risk factors and undiagnosed comorbidities.6
Bringing health as patients see it into focus
There are numerous recommendations for doctors to inform patients on a healthy lifestyle. The perspective is top down. Many doctors feel uncomfortable treating patients as people of little knowledge and acting as high priests of health. Self-rated health can change the perspective, starting with the patient’s own health situation. This starting point was proposed by GP Petre Jones and colleagues in their article ‘Coaching for health.’7 However, they proposed a more ambitious psychological approach not feasible in a GP surgery. Discussing self-rated health could be a way to coach for health within an ordinary GP consultation. This can be worthwhile as ‘patients have a remarkable potential to help themselves.’7 The aim could be to improve health or to maintain health even though there are medical diseases at hand.8 As one of my patients put it:
‘They tell me you should do this or that, eat this and not that, exercise, quit smoking, and blah blah blah. It’s all a waste on me. It is not the problem. It’s the spark missing.’
For this patient, coaching for health meant focusing on ‘the spark.’
Sensitive to social determinants of health
Self-rated health is sensitive to social determinants of health such as education, household wealth, or living conditions.1 A doctor cannot use self-rated health and remain unaware of social determinants of health.
DOUBTS ON SUBJECTIVE HEALTH PERSPECTIVES
But is subjective health a valid perspective for doctors trained in diagnosing and treating disease?
Yes it is. It is beyond any doubt that subjective health matters. It makes a difference in the lives of our patients, their longevity, and the outcome of their diseases.1 Thus, it must be a matter also for the patients’ doctors. David Misselbrook recently put this insight into writing, ‘Let’s help people to be well, not just tell them they are sick.’9
Is subjective health a reliable measure?
Yes it is. Self-rated health is a stable self-concept of health, formed in adolescence.10
It is impossible to know what self-rated health measures
This is indeed true. However, our patients do not live in a laboratory environment where there is a clear link between cause and effect. They live in a web of causes, interactions, and effect modifiers. The strength of self-rated health is its ability to sum up the net effect of multiple causes.
Lack of subjective health is not a diagnosis
Yet, for some patients this seems to be a greater problem than the diagnoses put on them by doctors. When this is the case it seems more appropriate to focus on subjective health rather than disease. In some instances this focus could even lead to new ways of assisting the patient. Far too often we come to an end in our medical treatment options.
Good health has little to do with doctors
GP Daniel Edgcumbe reminds us of the importance of the political arena on health issues.11 Health is not an end in itself. It is a means to accomplish the things you want in life. A certain amount of health and self-confidence is certainly needed if you are to act on the political arena and in society. Doctors can liberate patients and empower them to health rather than oppressing them with diagnosis, risk factors, and seeing problems. Focusing on self-rated health can help to empower patients.8
TIME TO IMPLEMENT
In practice
Questions of self-rated health are often formulated ‘How would you assess your general state of health?’ with answers ranging in five steps from excellent to poor. This type of question is the one most often used in epidemiological research. A more dialogue-enhancing question, semantically clearer, is the age-comparative variant: ‘How is your health compared to people of your age? Better, about the same or worse?’12 In my experience this question often elicits an immediate reaction and then a vocal reasoning by the patients assessing their health in one way or another. This reasoning can be used by the patient and doctor together. How it is used is of course dependent on the context in the actual consultation. There are definitely consultations where it is inappropriate to raise the question. Asking about self-rated health is more of an option available when needed for understanding the patient or help the patient to reflect on their own situation.
In research
There is a biological basis that ties self-rated health to hardcore endpoints, such as death or cardiovascular disease. There is an association between elevated levels of inflammatory markers and poor self-rated health.13 The association between self-rated health and inflammation was not accounted for by objective health diagnoses, medication use, or health behaviours. Thus, self-rated health provides unique information regarding inflammatory status above and beyond traditional objective health indicators.13 Allostatic load, a combined measure of biological dysregulation is related to self-rated health. Self-rated health in adolescence predicted allostatic load in young adulthood.10 The researchers argue that self-rated health formed early in life may be an important determinant for long-term health closely tied to physiological changes in the body. Further research on the relation between physiological changes and self-rated health seems a promising path for understanding self-rated health and its relation to outcomes and function. An even more pertinent question is whether interventions aimed at improving self-rated health also can improve patient-related outcomes.
SUMMARY
GPs meet patients and the patient’s assessment of their own health. The doctor’s job is to understand and deal with this assessment. Is there a disease that can be treated or alleviated? Is there something else that the patient or doctor can do? Can something be done to maintain and strengthen a good subjective health? To disregard the patient’s subjective view of health is equal to not using the most valuable piece of information there is. In some consultations, when appropriate, a question of self-rated health can be posed. There is a massive scientific base for the usefulness of self-rated health.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2015
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