A Comprehensive Clinical Model of Suffering
===========================================

* William R. Phillips
* Jane M. Uygur
* Thomas R. Egnew

## Abstract

Suffering is often a part of the illness experience, and relieving it is a fundamental obligation of medicine. Distress, injury, disease, and loss generate suffering when they threaten meaning in the patient’s personal narrative. Family physicians have exceptional opportunities and responsibilities to manage suffering through long-term continuity relationships, demonstrating empathy, and building trust over time and across problems. We propose a new Comprehensive Clinical Model of Suffering (CCMS) founded on the family medicine approach to whole-patient care. Comprehending that suffering can involve every aspect of a patient’s life, the CCMS is constructed on 4 axes and 8 domains that form a “Review of Suffering” to help clinicians recognize and manage patient suffering. Applied to clinical care, the CCMS can guide observation and empathetic questioning. Applied to teaching, it can provide a framework for discussions of complex and challenging patients. Barriers to applying the CCMS in practice include clinician training, time with patients, and competing demands. However, by structuring the clinical assessment of suffering, the CCMS may increase the efficiency and effectiveness of clinical encounters and improve patient care and outcomes. The application of the CCMS to patient care, clinical training, and research will require further evaluation.

*   Behavioral Medicine
*   Disease Management
*   Chronic Disease
*   Clinical Medicine
*   Communication
*   Comprehensive Health Care
*   Continuity of Patient Care
*   Empathy
*   End of Life Care
*   Family Medicine
*   Medical Ethics
*   Palliative Care
*   Patient-Centered Care
*   Primary Health Care
*   Suffering
*   Quality of Life

## Introduction

The relief of suffering is medicine’s ancient calling, primary goal, and the core of its ethics.1⇓–3 Yet, despite the centrality of suffering to medicine’s mission, there is little agreement about its definition and no bioethical consensus as to what it is.4,5

In his foundational work on suffering in medicine, Eric Cassell defined suffering as “the state of severe distress associated with events that threaten the intactness of the person.”6 According to Cassell, suffering is a personal, individual, subjective experience in which a person is distressed, feels a threat to personal intactness, is aware of a past and future, and ascribes meaning.6,7 Cassell’s model has dominated the dialogue about suffering for two generations but has been critiqued for being too stringent, logically inconsistent, and abstractly removed from clinical practice.8⇓⇓⇓⇓–13

At least in part because of this confusion, suffering and its relief are not a major focus of current medical education and clinical care.14⇓–16 It receives some attention in medical literature and medical school preclinical humanities curricula.16⇓⇓⇓⇓⇓⇓⇓⇓⇓–26 But patient suffering is rarely mentioned in clinical environments20,23 despite the distress it causes clinicians21 and the unfortunate potential for medical interventions to exacerbate rather than relieve it.27,28

Given its importance to medicine, its practitioners, and patients, a practical model of suffering is needed to apply to patient care and clinical environments. Drawing from literature across academic disciplines and helping professions, from interdisciplinary discussions with knowledgeable participants, and from clinical and teaching experience, we offer a Comprehensive Clinical Model of Suffering.

## Understanding Suffering

Suffering is personal, individual, related to threats to the integrity of self, and experienced by the whole person, not just the body.6,29⇓⇓⇓–33 It is a physical, biopsychosocial, existential, and spiritual phenomenon.34⇓⇓–37 Sufferers face losses, or threats of loss, associated with the deterioration of the body and the disintegration of self, values, belief systems, and connections to the world.38 They feel isolated, hopeless, and helpless.

Suffering is an inevitable aspect of human existence and belongs to life “as much as fate and death.”39,40 Its intensity ranges from distress to agony.6,29,41 Though unremitting pain may be a source, suffering differs from pain. It is existential angst related to a sense that one can no longer be the person one has known oneself to be.31

The disruption of previously held ways of relating to the world can thrust the sufferer into an abyss of meaninglessness.30 Whether an illness causes suffering “depends on the whole texture of meanings and values intrinsic to a particular patient’s unique life narrative.”42 Family members, loved ones, caregivers, and clinicians can likewise suffer because a patient’s condition has meanings and values linked to their own life narratives.43

Meaning in life differs from person to person and from moment to moment.44 Thus, suffering can only be understood as a lived experience involving a singularly personal tale related to meaning and value in one’s life.45,46 To comprehend the sufferer, one must explore their story of suffering.

## Suffering and the Promise of Family Medicine

Understanding another person’s suffering requires deep knowledge of their unique individuality.47 Contemporary medicine often fractionates patient care by diagnosis, age, gender, disease, organ system, and treatment method. Subspecialists providing episodic care may have less opportunity to gain the personal insight necessary to fully grasp patient suffering.

Family physicians—specialists in comprehensive continuity care for patients and families—are optimally positioned to detect and manage suffering. Comprehensive care is the management of “any health problem at any given stage of a patient’s life cycle”48 and involves “person-focused (not disease-oriented) care over time*.”*49 Comprehensive continuity care extends across the lifespan and includes the full spectrum of illness, loss, crisis, and death.

Family medicine carries the implicit commitment of the doctor to be present for the patient.50,51 Even when referring problems for subspecialty management, family physicians continue to follow their patients to witness their illness experience and suffering and to help ameliorate patient distress.51,52

Continuity begets a familiarity that helps the physician see the patient beyond the disease process. Through continuity, family doctors can counter some of the pressures of contemporary medicine,53 explore the patient’s story of suffering,16 and provide the type of care patients identify with ideal physicians54 who help them manage their suffering.

Diagnosing the disease identifies the pathologic processes in the body and may clarify treatment options to effect a cure, halt or slow its progression, or soothe accompanying symptoms. Caring for the patient, however, requires attention to their lived experience of illness in their personal psychological and social context.46

To provide more meaningful care, clinicians must go beyond diagnosis, symptoms, and treatments to validate the patient’s experience of illness and help the patient navigate toward wellness.55,56 To guide these efforts, we propose a model of suffering that encompasses these complexities yet is readily applicable to patient care.

## Developing a Model of Patient Suffering

Based on a broad review of literature across disciplines, our team employed a narrative integrative scholarship of synthesis approach57 to develop a model of suffering that would be practically applicable to patient care in the primary care setting. Our team represents extensive involvement in academic family medicine, clinical practice, clinical teaching, behavioral science in family medicine, patient-doctor communication, primary care research, interdisciplinary education and practice, personal experience of suffering and caregiving, and scholarship on empathy, compassion, suffering, and healing.

We moved in an iterative process from literature review to graphical modeling to schematically capture the nature of suffering and care as informed by our experience and the principles of family medicine: comprehensive, continuous, patient-oriented, whole-person, and relationship-based. We identified 4 axes and 8 dimensions to summarize a parsimonious model of suffering in the illness experience of the whole patient. Throughout the process, we invited review and comment from colleagues, expert clinicians, teachers, and scholars, to assure the model included the major components of patient suffering and was clinically applicable to primary care.

## The Comprehensive Clinical Model of Suffering

Illness is more than disease, care is more than diagnosis and treatment, and suffering involves every aspect of a patient’s life. Figure 1 graphically reflects the complexity of suffering summarized by the Comprehensive Clinical Model of Suffering (CCMS).

![Figure 1.](http://www.jabfm.org/https://www.jabfm.org/content/jabfp/36/2/344/F1.medium.gif)

[Figure 1.](http://www.jabfm.org/content/36/2/344/F1)

Figure 1. 
The Comprehensive Clinical Model of Suffering.

Patients usually consult their doctor for symptoms, problems, or needs they understand to be biomedical. Some encounters lead to precise diagnoses and specific treatments. However, particularly in comprehensive primary care, the patient’s “presenting complaint” often serves as an entry point to a longer story of a complex web of troubles, fears, losses, and suffering.

Conditions with clear biomedical pathophysiology impact other aspects of the patient’s life. Illness affects functions that are taken for granted when the patient is well.58 Socioculturally, these include important roles and relationships in the patient’s life. Psychobehaviorally, distressing thoughts and emotions develop as patients respond to the limitations and threats they encounter.

The CCMS places the patient at the center of a rich context that embraces the scope and breadth of the experience of suffering. It is constructed on 4 axes: biomedical, sociocultural, psychobehavioral, and existential. These axes encompass 8 domains: symptoms, functions, roles, relationships, emotions, thoughts, narrative, and worldview. Each dimension includes losses or threats of loss that can contribute to suffering (Table 1).

View this table:
[Table 1.](http://www.jabfm.org/content/36/2/344/T1)

Table 1. 
Matrix of Axes and Domains of Suffering with Clinical Examples

The biomedical axis is placed at the top, not because it is most important, but because it is the usual initial focus of the physician and expectation of the patient. The other axes reflect the depth and breadth of suffering that may be more important to some patients.36,59⇓–61

At the center of the model are the common patient experiences of suffering: distress, threat, loss, despair, and isolation. Surrounding the patient and shaping their unique experience of suffering is the patient’s perception of context. Laryngitis likely has a different meaning for a computer programmer working online than for a diva performing at La Scala.

We present the CCMS as a potential tool to help clinicians systematically investigate, organize, and understand the patient’s experience. We hope it can assist care teams to identify, discuss, and manage patient suffering collaboratively. Clinical testing and further research will be needed to assess its effectiveness to improve patient care and outcomes.

## The Model at Work

The CCMS offers a potentially practical tool to improve patient care, guide clinical teaching and learning, and inform future research on suffering and holistic healing.

In patient care, the CCMS might guide close observation and empathetic questioning to help clinicians and caregivers consider the general axes and specific domains of suffering. Every patient is unique, and each illness is a multi-dimensional experience.The model can aid navigation through this complexity by providing a menu of potential elements of suffering that clinicians may choose to explore in their discussions with patients. Identifying sources may help patients recognize implicit and ineffable aspects of their suffering. Explicitly discussing these tacit experiences may diminish their power.55,56

The 8 domains of suffering comprise a “Review of Suffering” (RoS) that complements the “Review of Systems” memorized by every medical student. Clinicians could use this new RoS to systematically consider each domain and how it might contribute to the patient’s narrative, distress, and suffering.

In clinical practice, understanding the patient’s view of self and the impact of their illness are the foundations of patient-centered care and create a starting point to facilitate holistic healing. A structured RoS can generate dialog, avoid blind spots, deepen clinical assessment, promote trust and empower doctor-patient communication. This may be particularly important in complex or otherwise challenging cases. The CCMS can help clinicians organize essential and often difficult discussions about suffering with patients, family members, caregivers, and clinical teams. It can also provide a structure for the documentation of suffering in the medical record.14,25

In clinical teaching, the CCMS could help attendings and trainees name and display dimensions of suffering and map the connections between them to enrich didactic teaching, bedside consultations, and case discussion conferences. The RoS might help learners interweave scientific medicine with humanism by connecting their assessments of patients with the bigger picture of illness and care25 while increasing their insight into their own feelings, stimulating their empathy, and broadening their perspectives of the role of the physician. Providing a practical clinical model can encourage teachers and learners to engage more actively and accurately with patients as whole persons. Systematic use of the CCMS to assess knowledge and skills about suffering in the same way we document other core clinical competencies could help establish suffering in both the formal and hidden curricula.23

In research, the CCMS provides a schema for identifying key domains and axes of patient suffering that can aid investigators in organizing their questions and work in ways more closely connected to the patient’s experience and the clinician’s work. The model can also be used to introduce the importance of patient suffering in evaluation and quality improvement in health care systems.

As a shared model, the CCMS can help organize conversations that sometimes get lost in clinical complexity, medical urgency, and competing goals. Such a model can help us learn more about our patients, their lives, goals, and experience of illness. This richer understanding and deeper care might also help us learn about ourselves.

## Patient Care Example

A brief patient care example in Appendix 1, Box A1 illustrates the everyday use of the CCMS to assess a patient’s suffering in a supportive way. Such discussion can enhance clinician and patient understanding, narrative editing, and holistic healing. Assessment of suffering includes close observation, deep listening, and synthesis of all clinical, social, and biomedical information. Questions proceed from the general to the specific and can focus on each of the 8 dimensions of suffering. The table linked to this clinical vignette (Appendix 1, Table A1) illustrates how the CCMS can help investigate, organize, understand, and begin to address the suffering this patient is experiencing.

Appendix 2 offers scripts of example questions clinicians can use to explore the domains of suffering in their patients.

Of course, not every question or domain pertains to each patient’s experience, and this work does not all need to be done in one visit. The primary care clinician can leverage the power of continuity over time and across problems to piece together the patient’s narrative of suffering. Working at this level challenges the family physician to use the refined clinical skills of patient-centeredness,62 agenda-setting,63 reaching common ground,64 shared decision making,65 goal-oriented care,66 relationship-centered care,67 and motivational interviewing.68

## Challenges and Barriers to Clinical Application of the Model

Factors that limit the ability of doctors to engage patient suffering include training, time, tools, and talent. Biomedical culture and education do not prepare trainees to manage suffering.23 Students focus on biomedical diagnosis and treatment of disease, not the patient’s personal experience of illness and suffering.19 Without guidance, training, and support,69,70 witnessing suffering can be stressful for students,71 and burnout hampers their ability to engage with it.72,73

As medicine has become an industry and medical services a commodity, administrative burdens for clinicians have escalated, and demands for efficiency increasingly drive clinical encounters.74,75 Time is money, and doctors are paid for doing things to patients, not for listening to them. There are no billing codes for exploring suffering. Clues to stories of suffering may be lost in the squeeze for efficiency.76

Technology distances doctors from patients and depersonalizes patients’ illness experiences.77⇓–79 Electronic medical records offer no drop-down lists to address patient suffering. Although some tools exist for assessing suffering in palliative care patients,80,81 none are designed for primary care.

Managing suffering depends on the clinician’s abilities, skills, and attitudes. Witnessing suffering with equanimity and demonstrating therapeutic empathy, warmth, and authenticity are clinical skills that can be taught and learned.82,83 But openness to the patient’s experience of suffering requires tolerance for emotional vulnerability, an aptitude variable among physicians.84,85

Despite these impediments, continuity allows family physicians to gain the deep understanding of their patients necessary to see, feel, and appreciate their suffering. If the clinician can recognize suffering and manage effective responses to patient needs, they can contribute to the healing process.52,86 This type of care is emotionally challenging, and clinicians who engage in this way must be willing to grow and learn with their patients.87,88 Those who explore their patients’ experiences of serious illness and help them edit their stories of brokenness often discover this to be some of the most fulfilling work of their careers.87,89 In a context of trust, caring, and understanding, patients can be helped to transcend their suffering.52,86

## Limitations

The CCMS model is limited, as any 2-dimensional model must be, and can only incompletely account for the complexity of illness, suffering, healing, and wholeness. Our process would have been enriched by including patients, caregivers, and families in the model’s development. These essential voices should be involved in any trials or evaluation studies.

Clinical application of the CCMS in primary care practice may be limited by factors that commonly frustrate clinicians. Issues of time and competing demands must be balanced across patient and clinician priorities. Explicit agenda setting, transparent clinician intent, and sample scripts can save time.64,90,91 The CCMS may make clinical encounters more efficient and effective by structuring the assessment of the complex experience of suffering. Helping patients address the sources of their suffering may also reduce unnecessary tests and consultations.

Accepting these significant limitations, we believe the CCMS can be helpful to clinicians, patients, and learners at all levels.

## Next Steps

The CCMS model warrants further development and testing that includes members of the care team, patients, family, and community members. The critical component of context deserves further emphasis and research. The influences of language, culture, and health care systems on patients and clinicians require further study across various settings. Social determinants of health, racism, and other forms of discrimination have important impacts on health, medical services, and the experience of suffering and healing and deserve further study.92⇓⇓–95

The next step is testing the model in clinical applications across the full spectrum of health, illness, life transition, and loss. Does the use of the CCMS improve the process and outcomes of care, relieve suffering, and facilitate holistic healing? How does it influence clinical effectiveness, efficiency, and professional satisfaction among the health care team?

Primary care is ideally suited to use and test this model across various care settings. However, as the relief of suffering is a goal shared by all caring professions,96 we encourage other clinicians to consider testing the CCMS in their practice and teaching.

The application of the CCMS to medical education can likewise be evaluated to determine whether its use broadens and deepens case discussions and teaching about patients, their needs, and their care, and whether such learning helps fledgling clinicians deliver more holistic care with better results.

## Closing Comment

The relief of suffering is an ancient obligation and now a pressing need for modern medicine. The challenges increase as advances in science mean that more patients live longer with chronic illnesses, endure more complex medical treatments, and survive and suffer longer near the end of life. Family physicians and other primary care clinicians care for these patients and their problems. The burdens of suffering continue to increase and beg relief for patients living with multimorbidity and polypharmacy,97 medically unexplained symptoms,98 chronic pain,99 substance use disorders,100 and long Covid.101

We hope this CCMS synthesizes scholarship, clinical experience, and family medicine perspectives for practical application to stimulate deeper thought, greater empathy, more systematic patient evaluation, and more effective and fulfilling patient care.

## Acknowledgments

We thank our colleagues for the insightful comments they contributed to this work: Larry B. Mauksch, Seattle, WA, USA; Mark Murphy, Dublin, IRE; and Hamish Wilson, Dunedin, NZ. Dr. Phillips thanks the Fulbright Commission in Ireland and the Department of General Practice at the Royal College of Surgeons in Ireland, Dublin, for their generous support of his work.

## Appendix 1. Patient Care Example of Using the Comprehensive Clinical Model of Suffering

  
</br>![][1]</img>

View this table:
[Table A1.](http://www.jabfm.org/content/36/2/344/T2)

Table A1. 
Domains of Suffering in the Patient Vignette

## Appendix 2. Example Clinical Questions to Explore Domains of Patient suffering

View this table:
[Table A2.](http://www.jabfm.org/content/36/2/344/T3)

Table A2. 
Exploratory Questions

## Notes

*   This article was externally peer reviewed.

*   *Funding:* none.

*   *Conflict of interest:* none.

*   To see this article online, please go to: [http://jabfm.org/content/36/2/344.full](http://jabfm.org/content/36/2/344.full).

*   Received for publication September 9, 2022.
*   Revision received November 1, 2022.
*   Accepted for publication November 3, 2022.

## References

1.  1.Callahan D. Managed care and the goals of medicine. J Am Geriatr Soc 1998;46:385–8.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9514393&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

2.  2.Cassell EJ. The importance of understanding suffering for clinical ethics. J Clin Ethics 1991;2:81–2.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=1932806&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

3.  3.Cassell EJ. *The Nature of Suffering and the Goals of Medicine*. New York, NY: Oxford University Press; 1991.
    
    

4.  4.Wilkinson I. *Suffering: A Sociological Introduction*. Cambridge, UK: Polity Press; 2005.
    
    

5.  5.Svaneus F. The phenomenology of suffering in medicine and bioethics. Theo Med Bioeth 2014;35:407–20.
    
    

6.  6.Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982;306:639–45.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJM198203183061104&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=7057823&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1982NF08800004&link_type=ISI) 

7.  7.Cassell EJ. *The Nature of Healing*. New York, NY: Oxford University Press; 2013.
    
    

8.  8.Gadow G. Suffering and interpersonal meaning. J Clin Ethics 1991;2:103–7.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11642919&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

9.  9.van Hooft S. Suffering and the goals of medicine. Med Health Care Philos 1998;1:125–31.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1023/A:1009923104175&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11081289&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

10. 10.Edwards SD. Three concepts of suffering. Med Health Care Philos 2003;6:59–66.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1023/A:1022537117643&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12710565&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

11. 11.Bishop JP. *The Anticipatory Corpse: Medicine, Power, and the Care of the Dying*. South Bend, IN: University of Notre Dame Press; 2011.
    
    

12. 12.Bueno-Gómez N. Conceptualizing suffering and pain. Philos Ethics Humanit Med 2017;12:7.
    
    

13. 13.Tate T, Pearlman R. What we mean when we talk about suffering—and why Eric Cassell should not have the last word. Perspect Biol Med 2019;62:95–110.
    
    

14. 14.Donnelly WJ. Taking suffering seriously: a new role for the medical case history. Acad Med 1996;71:730–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1097/00001888-199607000-00004&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9158340&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1996UX39400011&link_type=ISI) 

15. 15.Cassell EJ. The nature of suffering. Presented at: Grand Rounds at Dunedin School of Medicine; July 27, 1998; University of Otago, Dunedin, NZ.
    
    

16. 16.Epstein RM, Back AL. Responding to suffering. JAMA 2015;314:2623–4.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=26720023&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

17. 17.Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med 2009;7:170–5.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy8yLzE3MCI7czo0OiJhdG9tIjtzOjIwOiIvamFiZnAvMzYvMi8zNDQuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

18. 18.Kellehear A. On dying and human suffering. Palliat Med 2009;23:388–97.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/0269216309104858&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=19477888&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

19. 19.Lee TH. The word that shall not be spoken. N Engl J Med 2013;369:1777–9.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJMp1309660&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=24195546&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

20. 20.Egnew TR, Lewis PR, Schaad DC, Karrupiah S, Mitchell S. Medical student perceptions of medical school education about suffering: a multicenter pilot study. Fam Med 2014;46:39–44.
    
    

21. 21.Back AL, Rushton CH, Kaszniak AW, Halifax JS. “Why are we doing this?”: clinician helplessness in the face of suffering. J Palliat Med 2015;18:26–30.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1089/jpm.2014.0115&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=25555085&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

22. 22.Charon R. To see the suffering. Acad Med 2017;92:1668–70.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

23. 23.Egnew TR, Lewis PR, Myers KR, Phillips WR. Medical student perceptions of their education about suffering. Fam Med 2017;49:423–9.
    
    

24. 24.Wise M, Marchand LR, Roberts LJ, Chih M-Y. Suffering in advanced cancer: a randomized control trial of a narrative intervention. J Palliat Med 2018;21:200–7.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

25. 25.del Giglio A. Suffering-based medicine: practicing scientific medicine with a humanistic approach. Med Health Care Philos 2020;23:215–9.
    
    

26. 26.Tate T. What we talk about when we talk about pediatric suffering. Theor Med Bioeth 2020;41:143–63.
    
    

27. 27.Daneault S, Lussier V, Mongeau S, et al. Primum non nocere: could the health care system contribute to suffering? Can Fam Physician 2006;52:1574–5.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjEwOiI1Mi8xMi8xNTc0IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

28. 28.Gawande A. *Being Mortal: Medicine and What Matters in the End*. New York, NY: Metropolitan Books; 2014.
    
    

29. 29.Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care 1994;10:57–70. 1994.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=8089819&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

30. 30.1.  Ferrell BR
    
    Kahn DL, Steeves RH. An understanding of suffering grounded in clinical practice and research. In Ferrell BR ed. *Suffering*. Sudbury, MA: Jones and Bartlett Publishers; 1996:3–27.
    
    

31. 31.Chapman CR, Gavrin J. Suffering: the contributions of persistent pain. Lancet 1999;353:2233–7. 1999.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/S0140-6736(99)01308-2&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10393002&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000081091300044&link_type=ISI) 

32. 32.Reed FC. *Suffering and Illness: Insights for Caregivers*. Philadelphia, PA: F. A. Davis Company; 2003.
    
    

33. 33.Mount BM, Boston PH, Cohen SR. Healing connections: on moving from suffering to a sense of well-being. J Pain Symptom Manage 2007;33:372–88. 2007.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/j.jpainsymman.2006.09.014&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=17397699&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000245614900002&link_type=ISI) 

34. 34.Siler S, Borneman T, Ferrell B. Pain and suffering. Semin Oncol Nurs 2019;35:310–4.
    
    

35. 35.Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practices and scientific inquiry. Ann Fam Med 2004;2:576–82.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU3NiI7czo0OiJhdG9tIjtzOjIwOiIvamFiZnAvMzYvMi8zNDQuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

36. 36.Amonoo HL, Harris JH, Murphy WS, Abrahm JL, Peteet JR. The physician’s role in responding to existential suffering: what does it mean to comfort always? J Palliat Care 2020;35:8–12.
    
    

37. 37.Bartel M. What is spiritual? What is spiritual suffering? J Pastoral Care Counsel 2004;58:187–201.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/154230500405800304&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=15478953&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

38. 38.Kearsley JH. Therapeutic use of self and the relief of suffering. Cancer Forum 2010;34:98–101. Retrieved from [https://search.informit.org/doi/10.3316/informit.186759252534959](https://search.informit.org/doi/10.3316/informit.186759252534959).
    
    

39. 39.Dass R, Gorman P. *How Can I help?* New York, NY: Knopf; 1985.
    
    

40. 40.Frankl VE. *The Doctor and the Soul*. New York, NY: Knopf; 1965.
    
    

41. 41.Coulehan J. Compassionate solidarity: suffering, poetry, and medicine. Perspect Biol Med 2009;52:585–603.
    
    

42. 42.Toombs SK. The metamorphosis: the nature of chronic illness and its challenge to medicine. J Med Hum 1993;14:223–30.
    
    

43. 43.Farber SJ, Egnew TR, Herman-Bertsch JL, Taylor TR, Guldin GE. Issues in end-of-life care: patient, caregiver, and clinician perceptions. J Palliat Med 2003;6:19–31.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1089/10966210360510082&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12710572&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

44. 44.Frankl VE. *Man’s Search for Meaning: An Introduction to Logotherapy*. Boston, MA: Beacon; 2006.
    
    

45. 45.1.  Romanucci-Ross L, 
    2.  Moerman D, 
    3.  Tancredi L
    
    Moerman DE. Physiology and symbols: the anthropological implications of the placebo effect. In Romanucci-Ross L, Moerman D, Tancredi L eds. *The Anthropology of Medicine: From Culture to Method*. South Hadley, MA: J. F. Bergin Publishers; 1983:156–67.
    
    

46. 46.Toombs SK. The meaning of illness: a phenomenological approach to the patient-physician relationship. J Med Philos 1987;12:219–40.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1093/jmp/12.3.219&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=3668399&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1987J797400002&link_type=ISI) 

47. 47.Cassell EJ. Recognizing suffering. Hastings Ctr Rep 1991;21:24–31.
    
    

48. 48.Peterson ML. The Institute of Medicine report, “A manpower policy for primary health care”: a commentary from the American College of Physicians. Introduction and discussion. Ann Intern Med 1980;92:843–51.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=6104460&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1980JW13400022&link_type=ISI) 

49. 49.Starfield B. Primary Care: Balancing Health Needs, Services and Technology. 2nd ed. New York, NY: Oxford University Press; 1998.
    
    

50. 50.Loxterkamp D. Being there: on the place of the family physician. J Am Board Fam Pract 1991;4:354–60.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czo1OiJqYWJmcCI7czo1OiJyZXNpZCI7czo3OiI0LzUvMzU0IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

51. 51.Phillips WR, Haynes DG. The domain of family practice: scope, role, and function. Fam Med 2001;33:273–7.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11322520&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000167959600008&link_type=ISI) 

52. 52.Egnew TR. A narrative approach to healing chronic illness. Ann Fam Med 2018;16:160–5.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTYvMi8xNjAiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzM2LzIvMzQ0LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

53. 53.Nowak DA, Sheikhan NYU, Naidu SC, Kuluski K, Upshur REG. Why does continuity of care with family doctors matter? Review and qualitative synthesis of patient and physician perspectives. Can Fam Physician 2021;67:679–88.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjg6IjY3LzkvNjc5IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

54. 54.Bendapudi NM, Berry LL, Frey KA, Parish JT, Rayburn WL. Patients’ perspectives on ideal physician behaviors. Mayo Clin Proc 2006;81:338–44.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.4065/81.3.338&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16529138&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000235740700011&link_type=ISI) 

55. 55.Benitez C, Howard KP, Cheavens JS. The effect of validation and invalidation on positive and negative affective experiences. J Posit Psychol 2022;17:46–58.
    
    

56. 56.Tietbohl CK. Empathic validation in physician-patient communication: an approach to conveying empathy for problems with uncertain solutions. Qual Health Res 2022;32:413–25.
    
    

57. 57.MacGaghie WC. Varieties of integrative scholarship. Acad Med 2015;90:294–302.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1097/ACM.0000000000000585&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=25494401&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

58. 58.Baron RJ. An introduction to medical phenomenology: I can’t hear you while I’m listening. Ann Intern Med 1985;103:606–11.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.7326/0003-4819-103-4-606&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=4037561&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1985ASA5200020&link_type=ISI) 

59. 59.Yager J. Addressing suffering in patients with psychiatric disorders. J Nerv Ment Dis 2021;209:615–21.
    
    

60. 60.Balboni TA, VanderWeele TJ, Doan-Soares SD, et al. Spirituality in serious illness and health. JAMA 2022;328:184–97.
    
    

61. 61.Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender and queer Americans. Health Serv Res 2019;54:1454–66.
    
    

62. 62.Stewart M, Brown JB, Weston WW, et al. *Patient-Centered Medicine: Transforming the Clinical Method*. Thousand Oaks, CA: Sage Publications; 1995.
    
    

63. 63.Mauksch LB, Hillenburg L, Robins L. The establishing focus protocol: training for collaborative agenda setting and time management in the medical interview. Fam Sys Health 2001;19:147–57.
    
    

64. 64.Wagner EH, Bennett SM, Austin BT, et al. Finding common ground: patient-centeredness and evidence-based chronic illness care. J Alt Compl Med 2005;11:s-7–15.
    
    

65. 65.Stiggelbout AM, Van der Weijden T, De Wit MTP, et al. Shared decision making: really putting patients at the centre of healthcare. BMJ 2012;344:e256.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE2OiIzNDQvamFuMjdfMS9lMjU2IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

66. 66.Mold JW. *Goal-Oriented Medical Care: Helping Patients Achieve Their Personal Health Goals*. Englewood Cliffs, NJ: Full Court Press; 2020.
    
    

67. 67.Beach MC, Inui T, Relationship-Centered Care Research Network. Relationship-centered care: A constructive reframing. J Gen Intern Med 2006;21:S3–S8.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1111/j.1525-1497.2006.00302.x&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

68. 68.Keeley R, Engel M, Reed A, Brody D, Burke BL. Toward an emerging role for motivational interviewing in primary care. Curr Psychiatry Rep 2018;20:41.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1007/s11920-018-0901-3&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=29777318&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

69. 69.Weng HY, Fox AS, Shackman AJ, et al. Compassion training alters altruism and neural responses to suffering. Psychol Sci 2013;24:1171–80.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/0956797612469537&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=23696200&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

70. 70.Rosenberg EL, Zanesco AP, King BG, et al. Intensive meditation training influences emotional responses to suffering. Emotion 2015;15:775–90.
    
    

71. 71.Egnew TR, Lewis PR, Meyers KR, Phillips WR. The suffering medical students attribute to their undergraduate medical education. Fam Med 2018;50:296–9.
    
    

72. 72.Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ 2016;50:132–49.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1111/medu.12927&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=26695473&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

73. 73.Hansell MW, Ungerleider RM, Brooks CA, Knudson MP, Kirk JK, Ungerleider JD. Temporal trends in medical student burnout. Fam Med 2019;51:399–404.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

74. 74.Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos 1999;24:243–66.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1076/jmep.24.3.243.2523&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10472814&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000082452700003&link_type=ISI) 

75. 75.Rastegar DA. Health care becomes an industry. Ann Fam Med 2004;2:79–83.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiMi8xLzc5IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

76. 76.Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284:1021–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/jama.284.8.1021&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10944650&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000088769000031&link_type=ISI) 

77. 77.Thomas L. *The Youngest Science*. New York, NY: Bantam Books; 1983.
    
    

78. 78.Broyard A. *Intoxicated by My Illness*. New York, NY: Fawcett Columbine; 1992.
    
    

79. 79.Toll E. The cost of technology. JAMA 2020;323:1661–2.
    
    

80. 80.Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician 2001;63:81–9.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11195773&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000166414400007&link_type=ISI) 

81. 81.Chochinov HM, Hassard T, McClement S, et al. The patient dignity inventory: a novel way of measuring dignity-related distress in palliative care. J Pain Symptom Manage 2008;36:559–71.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/j.jpainsymman.2007.12.018&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=18579340&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000262023500001&link_type=ISI) 

82. 82.Hubble MA, Duncan BL, Miller SC. *The Heart & Soul of Change: What Works in Therapy*. Washington, DC: American Psychological Association; 1999.
    
    

83. 83.Batt-Rawden SA, Chisolm MS, Blair A, Flickinger TE. Teaching empathy to medical students. Acad Med 2013;88:1171–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1097/ACM.0b013e318299f3e3&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=23807099&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000325702400037&link_type=ISI) 

84. 84.Cassell EJ. Diagnosing suffering. Ann Intern Med 1999;131:531–4.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.7326/0003-4819-131-7-199910050-00009&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10507963&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000083018800007&link_type=ISI) 

85. 85.Farber SJ, Egnew TR, Herman-Bertsch JL. Issues in end-of-life care: family practice faculty perceptions. J Fam Pract 1999;49:525–30.
    
    

86. 86.Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med 2005;3:255–62.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMy8zLzI1NSI7czo0OiJhdG9tIjtzOjIwOiIvamFiZnAvMzYvMi8zNDQuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

87. 87.Farber SJ, Egnew TR, Herman-Bertsch JL. Defining effective clinician roles in end-of-life care. J Fam Pract 2002;51:153–8.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11978213&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000173776900008&link_type=ISI) 

88. 88.Sedhom R, Sedhom D. To grow as a physician, try responding to suffering. J Palliat Care 2019;34:3–4.
    
    

89. 89.Uygur J, Brown JB, Herbert C. Understanding compassion in family medicine: a qualitative study. Br J Gen Pract 2019;69:e208–e216.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYmpncCI7czo1OiJyZXNpZCI7czoxMToiNjkvNjgwL2UyMDgiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzM2LzIvMzQ0LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

90. 90.Duke P, Frankel RM, Reis S. How to integrate the electronic health record and patient-centered communication into the medical visit: a skills-based approach. Teach Learn Med 2013;25:358–65.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1080/10401334.2013.827981&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=24112206&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

91. 91.Gavinski K, Covin YN, Longo PJ. Learning to build illness scripts. Acad Med 2019;94:293.
    
    

92. 92.Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of causes.Public Health Rep 2014;129:19–31.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/003335491412900105&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=24381356&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

93. 93.Hamed S, Bradby H, Ahlberg BM, Thapar-Bjökert. Racism in healthcare: a scoping review. BMC Pub Health 2022;22:988.
    
    

94. 94.Trent M, Dooley DG, Dougé Jet al. The impact of racism on child and adolescent health. Pediatrics 2019;144:e20191765.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1542/peds.2019-1765&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=31358665&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

95. 95.Krieger N. Discrimination and health inequities. Int J Health Serv 2014;44:643–710.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.2190/HS.44.4.b&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=25626224&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

96. 96.Egnew TR. A philosophy for behavioral health integration in primary care. Fam Syst Health 2017;35:18–20.
    
    

97. 97.Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ 2015;350:h176.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE2OiIzNTAvamFuMjBfMi9oMTc2IjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNi8yLzM0NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

98. 98.Hubley S, Uebelacker L, Eaton C. Managing medically unexplained symptoms in primary care: a narrative review and treatment recommendations. Am J Lifestyle Med 2016;10:109–19.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1177/1559827614536865&link_type=DOI) 

99. 99.Mills S, Torrance N, Smith BH. Identification and management of chronic pain in primary care: a review. Curr Psychiatry Rep 2016;18:22.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1007/s11920-015-0659-9&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=26820898&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom) 

100.100.Volkow ND. Personalizing the treatment of substance abuse disorders. Am J Psychiatry 2020;177:113–6.
    
    

101.101.Rushforth A, Ladds E, Wieringa S, Taylor S, Husain L, Greenhalgh T. Long Covid–the illness narratives. Soc Sci Med 2021;286:114326.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F36%2F2%2F344.atom)

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