Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.

Organizing care for patients with chronic illness.

Hope is defined as the perceived capability to derive pathways to desired goals, and motivate oneself via agency thinking to use those pathways. The adult and child hope scales that are derived from hope theory are described. Hope theory is compared to theories of learned optimism, optimism, self-efficacy, and self-esteem. Higher hope consistently is related to better outcomes in academics, athletics, physical health, psychological adjustment, and psychotherapy. Processes that lessen hope in children and adults are reviewed. Using the hope theory definition, no evidence is found for "false" hope. Future research is encouraged in regard to accurately enhancing hope in medical feedback and helping people to pursue those goals for which they are best suited.

Hope theory: Rainbows in the mind.

On death and dying

Discourse in the Novel

The National Academy of Sciences through its Institute of Medicine (IOM) has produced a major scholarly assessment of pain in America. This document is a tremendous contribution to the evolving nec...

Relieving pain in america: a blueprint for transforming prevention, care, education, and research

The question of suffering and its relation to organic illness has rarely been addressed in the medical literature. This article offers a description of the nature and causes of suffering in patients undergoing medical treatment. A distinction based on clinical observations is made between suffering and physical distress. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians' failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. (N Engl J Med. 1982; 306:639–45.)

The Nature of Suffering and the Goals of Medicine

The alleviation of suffering is crucial in all of medicine, especially in the care of the dying. Suffering cannot be treated unless it is recognized and diagnosed. Suffering involves some symptom or process that threatens the patient because of fear, the meaning of the symptom, and concerns about the future. The meanings and the fear are personal and individual, so that even if two patients have the same symptoms, their suffering would be different. The complex techniques and methods that physicians usually use to make a diagnosis, however, are aimed at the body rather than the person. The diagnosis of suffering is therefore often missed, even in severe illness and even when it stares physicians in the face. A high index of suspicion must be maintained in the presence of serious disease, and patients must be directly questioned. Concerns over the discomfort of listening to patients' severe distress are usually more than offset by the gratification that follows the intervention. Often, questioning and attentive listening, which take little time, are in themselves ameliorative. The information on which the assessment of suffering is based is subjective; this may pose difficulties for physicians, who tend to value objective findings more highly and see a conflict between the two kinds of information. Recent advances in understanding how physicians increase the utility of information and make inferences allow one to reliably use the subjective information on which the diagnosis and treatment of suffering depend. Knowing patients as individual persons well enough to understand the origin of their suffering and ultimately its best treatment requires methods of empathic attentiveness and nondiscursive thinking that can be learned and taught. The relief of suffering depends on physicians acquiring these skills.

Diagnosing suffering: a perspective.

Talking with patients

Beyond drugs, beyond technology, there will always be the human element, "the healer's art." Dr. Cassell discusses the world of the sick, the healing connection and healer's battle, the role of omnipotence in the healer's art, illness and disease, and overcoming the fear of death.Eric J. Cassell, M.D., is an internist and clinical director of the Program for the Study of Ethics and Values in Medicine at Cornell Medical School. His two-volume work Talking with Patients: The Theory of Doctor-Patient Communication, and Clinical Technique, is available from The MIT Press in cloth and paperback.

The Healer's Art

Background: Earlier anecdotal observations suggested to us that certain aspects of judgment in sick adults approximate the thinking of children. Objective: To describe changes in judgment associated with serious illness in otherwise competent adults. Design: Cohort study. Setting: Urban acute-care hospital and senior citizen center. Participants: Sicker (Karnofsky score ≤ 50; n = 24) and less sick (Kamofsky score > 50; n = 39) hospitalized patients were compared with controls (n = 28). Normal performance on the Mini-Mental State Examination (score ≥ 24) was required for study entrance. Measurements: Seven Piagetian tasks of judgment designed to study childhood cognitive development. Degree of sickness was determined by using the Kamofsky scale of physical function. Results: Patients with Kamofsky scores of 50 or less responded correctly to fewer Piagetian tasks than controls (mean [±SD], 1.8 ± 2.6 vs. 5.9 ± 1.6; p < 0.001). Furthermore, a smaller proportion of sicker patients responded correctly to each of the seven tasks. Patients with Kamofsky scores greater than 50 did not perform differently than controls. Conclusion: In sicker hospitalized patients, performance on seven Piagetian tasks of judgment was similar to that among children younger than 10 years of age. This evidence of cognitive impairment warrants further investigation.

Eric J. Cassell

Papers

The Nature of Suffering and the Goals of Medicine

Diagnosing suffering: a perspective.

Talking with patients

The Healer's Art

Preliminary evidence of impaired thinking in sick patients.