Working in a general medical practice sometimes feels like being at the greeting station of a Ferris wheel: Every few minutes another person gets off and brings a new set of medical issues into your office.
My first patient on a recent Thursday was a buoyant 71-year-old. Her rotator cuff tendinitis was an occasional bother, as was her allergic rhinitis, but neither got in the way of her picking up her school-age grandchildren every afternoon for a daily playground outing. On rainy days they danced to hip-hop music in her living room, and she showed me the video on her phone.
My next patient was only 43, but his kidneys were grinding to a halt under the weight of two decades of poorly controlled diabetes. Dialysis was looming in the near future, and he alternated between being depressed about it and being in denial of it. Every one of our visits had a funereal atmosphere as we discussed the logistics of something he desperately wanted no part of.
And so it went over the course of the day, changing gears on a dime with each new patient. Along with a swinging pendulum of medical conditions came a similar array, it seemed, of emotions.
The correlation of happiness and health — or unhappiness and poor health — has been noted over the centuries. “He who can believe himself well, will be well,” wrote Ovid, whose robust trope continues to find fertile ground in our current culture of wellness and self-help as well as in a burgeoning body of scientific research. But teasing out cause and effect is thorny.
On one hand, mood could drive health. Happy people are more likely to make salutary choices in their life — exercise, eat their veggies, get regular medical care — and so will become more healthy. When you are depressed or lonely, however, it can be hard to exercise, and that pint of cookie-dough ice cream may seem more welcoming than the chia-kale casserole wilting at the back of the fridge.
On the other hand, health may be the instigator of mood. If you are healthy, you tend to feel good. Having energy allows you to pursue the things you enjoy, and this makes you happy. When you are sick, though, you feel lousy and exhausted — not to mention saddled with medical bills — so it’s hard to pursue the joyful activities of life.
The latest entry in the health and happiness field — the Million Women Study — appears to poke a hole in the accepted dictum that well-being is a driver of good health. By far the largest study on the subject to date, it followed its cohort of middle-aged women in Britain for 10 years. The data showed an association of poor health and unhappiness. But after adjusting for medical conditions, demographics and lifestyle factors, unhappiness was not an independent predictor of increased mortality.
There have been critiques of the study methodology. The evaluation of happiness, for example, was based on a single question and focused on only one moment in time. Controlling for factors like smoking, exercise, income and marital status for the benefit of clean statistics may have ended up eradicating the very mechanisms by which happiness may improve health: quitting smoking, exercising, holding down a good job, staying married.
Small studies have hinted at causality by demonstrating that interventions to increase positive feelings yield improved physiological measurements. But we’ll never be able to answer the question in the purest scientific methodology — randomizing people to happy lives or miserable lives and then following them for a lifetime to see what happens.
Nevertheless, the association of happiness and health remains a potent touchstone in both popular and medical culture. In practical terms, which actually causes the other is less relevant than the fact that both are important. If a patient has poor health and is also feeling miserable, it’s not enough just to address the medical problem. How a person is feeling emotionally needs to be acknowledged and explored.
Doctors, of course, can’t solve the economic, societal and interpersonal challenges that cause unhappiness, but attention to the inner sense of suffering is helpful above and beyond our treatments for the disease itself.
But the opposite may offer an even more powerful payoff. When doctors notice unhappiness in their patients, they should be probing more carefully for hidden illness. Beyond uncovering disorders such as depression, for which unhappiness is a direct symptom, there may be other illnesses lurking.
On a busy clinic day, each time a new person steps off that Ferris wheel into a medical evaluation there are a host of boxes to check off — height, weight, blood pressure, pulse. Lord knows I don’t want to see a “happiness” check-box in the electronic medical record. But the patient’s sense of well-being is something that should definitely register beyond the minor afterthought that it typically merits.
We in the health care professions need to notice and inquire about happiness the same way we do other aspects of our patients’ lives. Lately I’ve started asking about it, and besides getting a much more nuanced understanding of who they are as people, I learn what their priorities are (often quite different from mine as their physician).
I also inquire about obstacles to their happiness, and brainstorm with them on ways to ease some of these. I don’t presume that these challenges are facile to solve, but hopefully our conversation helps let patients know that their happiness matters as much as their cholesterol.
And if increasing happiness does in fact improve health — well, why not try to help our patients achieve it. The side effect profile and cost surely beat most of our current medications, and, at least for now, you don’t have to get prior authorization from an insurance company.
Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Our Perception of Perfection at TEDMED.