Family physicians and health promotion

Most family physicians regularly dispense health advice to their patients: Stop smoking. Exercise. Eat a healthy diet. This advice-giving is part of their role or, to put it more elegantly, it is part of the professional competencies that all family physicians must have. How could it be otherwise? How could we not recommend that an obese patient lose weight or that a patient with chronic bronchitis stop smoking? This simply goes without saying.

The doctor’s office is not the only place where health advice is dispensed—newspapers, magazines, television, and websites all offer advice on staying healthy or getting healthy, and that’s not counting all of the other health care providers who make suggestions.

Hence, there is no lack of information out there on health. But is it actually useful? Does it have a positive effect on patient health? Does it help people to live longer? Or healthier?

I asked myself these questions when I read “Mental health and the relationship between health promotion counseling and health outcomes in chronic conditions. Cross-sectional population-based study,” which appears on page e113.¹ Al Sayah et al aimed to determine whether there was a relationship between the health advice offered by family physicians and quality of life and the use of health services by patients with chronic diseases, with a special focus on the effect that patient mental health had on these determinants. They found that there is a relationship between health promotion counseling by family physicians and the indicators of quality of life and emergency department visits, but not hospitalization rates. Patients who receive health promotion counseling from their family physicians do adopt a healthier lifestyle and make fewer trips to the emergency department. This is an interesting finding; it reassures us that our role as a health counselor is important. It is consistent with the findings of other research studies demonstrating a relationship between health promotion and the adoption of healthy behaviour.

However, this study also made some troubling discoveries. First, physician commitment to health counseling was not as high as one would expect: patients reported that (only!) about 50% to 60% of physicians provided health counseling. This might be owing to the fact that this is a retrospective study based on patient opinions. Or is it possible that patients forgot their physicians’ valuable advice? It’s possible ...

Another troubling finding was that health advice dispensed to patients grappling with chronic health problems and mental health problems appeared to have no effect on either the adoption of healthy behaviour or the number of emergency department visits. How is this possible, especially when we consider that the mental health problems in these cases were not problems such as schizophrenia, with delusion, mutism, and hallucinations that would make it impossible for a patient to follow the physicians’ advice? They were, essentially, depressive disorders and anxiety disorders—conditions experienced by many of the patients who consult us. Among the 17% of patients in this study who had depression or anxiety, no association was found between the counseling variables and the quality-of-life variables or emergency department trips. It is as if health promotion had no effect at all on patients who were anxious or depressed.

This makes sense. When a patient is anxious, cannot sleep, or is “on edge”; or when he is depressed, discouraged, or overcome with sadness or despair, it is hardly the time to offer advice on managing a chronic health problem. Nor is it a good time to suggest exercise or a change in diet!

These situations illustrate the potential disconnect between the physician’s agenda and the patient’s agenda. It is perfectly understandable that, under certain circumstances, some family physicians will conclude that health promotion is inappropriate. Who among us would tell a patient who has just lost a loved one or who is in some sort of psychological distress that it is time she quit smoking or ate better? That would be indicative of a lack of judgment on our part.

In other words, health promotion is a good thing, just not all the time or under all circumstances.

It comes down to common sense.

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