Taking suffering seriously: a new role for the medical case history

The relief of suffering is commonly cited as a principal goal of clinical medicine. Yet suffering receives little attention in medical case histories, except for symptoms of pain or dysfunction that are useful diagnostically or in following the course of known disease and evaluating the effects of treatment. Contemporary attempts to deal more formally with suffering--the patient's personal experience of sickness or disability--by recording that information in case histories and medical records began with the problem-oriented medical record and continue with various proposals to include the "patient's perspective" or the "patient's review" in case presentations or records of medical care. Medicine's commitment to the relief of suffering is a compelling warrant to make the identification of the patient's perspective a major goal of historical inquiry and representation, beginning with a "history of present illness" that describes the patient's sickness or disability from two perspectives: that of the disease (a biomedically oriented account of the patient's sickness) and that of the illness (a description of the patient's personal situation, sufferings, perplexities, hopes, and fears). Experience with an earlier version of this reform suggests that optimal understanding and implementation of such a dual-perspective history by students and their instructors requires concomitant study of such matters as the goals of clinical medicine and the nature of suffering.