Background

While illness and disability are common[1], caring for patients coping with illness, disability, or injury can be challenging. They are suffering, and in medicine, we witness a lot of suffering. Sometimes our challenge in caring for these patients stems from just learning the skill to diagnose a patient’s condition and to develop patient-centered treatment plans. Other times, the challenge isn’t our cognitive approach, but the effect of our reaction to the suffering we see.

The reactions toward a patient’s suffering can be evoked by a wide array of factors, such as the following:

• our perception of the severity of one’s illness/disability and its impact on what we consider to be “normal” life
• our perception of suffering as unfair or unfortunate, avoidable or unavoidable
• our perception and/or judgment of the relationship between one’s illness/disability/suffering and their lifestyle choices (deserved v. undeserved)
• our patient’s age, role in their family (parent, child, etc.), and social status
• the rapidity with which one’s symptoms develop and one’s illness progresses
• the extent to which we can relate and/or identify with our patient, or how much our patient reminds us of someone we’ve known in the past
• the likelihood that one’s suffering is temporary or permanent; progressive or not

During the panel session on 11/6/2018, our colleagues will share their narratives, including those associated with: illness and injury; trauma and disease; and varying degrees of prognostic uncertainty. I hope that your consideration of these narratives and the session readings on this page will afford each of you the opportunity to reflect on your reactions to the nature of suffering, our place as clinicians witnessing and managing it, the extent to which we characterize or judge our own suffering and that of our patients,’ and the impact that may have on future patient care.

In addition, I want you to consider the nature of resilience. In medicine, we also witness the incredible resilience of human nature. This has been a buzzword in the last few years, but a disproportionate amount of literature suggests that resilience is both innate and can be bolstered. It is not a trait, but a process, and it is not rare.  It is also not a state of being constantly positive, but actually a reflection of proper coping techniques developed over time to navigate around crises.

Factors that contribute to resilience in patients include the following:

• The ability to manage strong impulses and feelings (REACTIONS)
• The ability to make realistic plans and being capable of taking the steps necessary to follow through with them (PLAN)
• A positive self-concept and confidence in one’s strengths and abilities (CONTEXT)
• Communication and problem-solving skills

Just pointing out the connection……

Two additional points:

1: Terminology and how we label:

The word suffering is sometimes used in the narrow sense of physical pain, but often it refers to mental pain, or more often yet it refers to pain in the broad sense, i.e. to any unpleasant feeling, emotion or sensation.  I changed the title for this session from “Illness and Disability” to “Suffering and Resilience,” because the relative emotional weight of the latter two words, I think, provokes us to think about the nature of suffering and of resilience, in the context of the wide array of illness, injury and disability we see as providers. Even for those who have seen or experienced illness and injury to this point, the idea of suffering as a part of illness/injury should evoke some thought about how we characterize and place value or judgment on suffering, which may or may not be seen as a “negative” term.  Similarly, resilience has a naturally “positive” spin – patients who are resilient “bounce back” and “adapt and overcome.”

I hope that, during this session, you will think about words that are commonly used to describe those with physical or mental challenges and how they shape your thinking.  As an example, words like invalid and crippled are less commonly heard today, replaced in many cases by the word handicapped (etymology here).  I also hope that you consider the use of words to define someone as opposed to describing their situation (the difference between saying “the diabetic in bed 4” as compared to “Mrs. Jones, a 54 year old woman who has diabetes”). You might wonder what all the fuss is about and perceive this as an effort to be politically correct. In actuality, how we label our patients has the potential to negatively impact our patients, but more importantly, our use of language shapes the way we think about and care for others.

Note 2: Range of Human Suffering Is Vast:

The range of illness we, as humans, experience is vast – acute and chronic; treated surgically and medically; affecting young and old; the list goes on and on.  Given the time limitations of the panel, representing every aspect of suffering would be impossible.  This is where the supplemental resources are so valuable – offering greater breadth for your consideration.  There are resources addressing disability, addiction, the illness of a child, mental illness and a few others. I hope you find one that resonates.

[1] The CDC reports that nearly 50% of all adults in the United States have at least one chronic illness while the NHIS reports that 19.4% of all people in the United States have a disability. Given this reality, each of us will commonly encounter patients, friends, and family members who live with chronic illness.

Assignment

Objectives:

• Reflect on and identify one’s reaction to illness, injury, pain, suffering, and resilience.
• Explore one’s personal context with regard to suffering and resilience.
• Analyze the implications, both positive and negative, of one’s reactions when faced with one’s own or one’s patient’s suffering and/or resilience in the face of illness, disability, injury, etc.
• Identify a plan for addressing these implications in the future.

Assignment:

1. Reflect on an experience in which you have suffered, witnessed someone suffering, and/or in which you found resilience. (Stories can be about suffering and resilience – the degree to which you or someone else suffered, and was or was not resilient, etc).
   1. Set the stage so the reader understands the context of the experience you are describing.
   2. Identify your reaction to:
      1. Suffering (being ill/injured) or seeing someone else suffer
      2. If resilience was part of your story, describe how it manifested.
      3. Experiencing a limitation in your ability to engage in your normal activities
   3. Identify at least ONE reaction to either the panelists’ narratives and/or resources that struck you as particularly thought-provoking with respect to suffering and/or resilience.

Sources: Explore the sources of each reaction. When writing this section, be specific about your experiences and the sources of your perceptions that have shaped your personal context and impact your perspective as it relates to this topic.  In addition, consider sources from multiple phases of your life to date to include:

• your own experience with suffering
• the role fitness and health play in your self-image and perception of others
• your experiences interacting with others, including family and friends, who have a chronic illness, injury, and/or disability or who have suffered in another way
• your perception of suffering and resilience are viewed in your family of origin and among your peers
• your perceptions of how suffering and resilience are viewed in the communities of which you have been a part, including the military and medical communities

Implications: Analyze and describe both the positive and negative implications of each of your reactions for how you might care for patients with illness and/or injury in the future.

Plan: Develop a specific, realistic plan you can implement today to mitigate the negative and enhance the positive implications described in the section above. Consider what you’ve learned about yourself in reflecting on suffering and resilience, and what behaviors and/or tools you would want to build going forward as you think about the suffering and resilience you will experience and witness.

Panelists

• ENS Kurt Christen is an MD candidate for the SOM class of 2019.
• Dr. Katie Snyder, LCDR, USN, is a family physician currently stationed at Quantico.
• SGT Jon Harmon is the liaison officer for members of the 82nd Airborne Regiment at Walter Reed.