The New England journal of medicine
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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 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.
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We studied seven patients with idiopathic Bence Jones proteinuria (excretion greater than 1.0 g per 24 hours) who did not have acquired Fanconi's syndrome or an intact monoclonal immunoglobulin in the serum. None had evidence of overt multiple myeloma, of its variants, of systemic amyloidosis, or of malignant lymphoproliferative diseases when the proteinuria was recognized. In three of the seven patients, symptomatic multiple myeloma (associated with systemic amyloidosis in one) developed 8.8 to 21.1 years later. ⋯ The remaining two patients still have apparently benign Bence Jones proteinuria after 7.7 and 12 years. Plasma-cell labeling indexes were low in all cases tested. This experience shows that although idiopathic Bence Jones proteinuria may remain stable for years, multiple myeloma or amyloidosis often develops, and consequently these patients must be kept under observation indefinitely.
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Randomized Controlled Trial Clinical Trial
A randomized trial of continuing medical education.
To determine whether continuing medical education affects the quality of clinical care, we randomly allocated 16 Ontario family physicians to receive or not receive continuing-education packages covering clinical problems commonly confronted in general practice. Over 4500 episodes of care, provided before and after study physicians received continuing education, were compared with preset clinical criteria and classified according to quality. Although objective tests confirmed that the study physicians learned from the packages, there was little effect on the overall quality of care. ⋯ When the topics were not preferred, however, the documented quality of care provided by study physicians rose (P less than 0.05) and differed from that provided by control physicians (P = 0.01). Finally, there was no spillover effect on clinical problems not directly covered by the program. In view of the trend toward mandatory continuing education and the resources expended, it is time to reconsider whether it works.