S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw organic disease and in such cases the determination of the causes of the dif symptoms may be an extremely difficult matter. Every one accepts the relationship between the common functional symptoms and nervous reactions, for convincing evidence is to be found in the fact that under ordinary circumstances the symptoms disappear just as soon as the emotional cause has passed But what happens if the cause does not pass away? What if, instead of having to face a single three-hour examination, one has to face a life of being constantly on the rack? The emotional stimulus persists, and continues to produce the disturbances of function. As with all nervous reactions, the longer the process goes on, or the more equently it goes on, the easier it is for it to go on. The unusual nervous track becomes an established path. After a time, the symptom and the subjective discomfort that it produces come to occupy the center of the picture, and the causative factors recede into a hazy background. The patient no longer thinks"I cannot stand this life, "but he says out loud"I cannot stand this nausea and vomiting I must go to see a stomach specialist. Quite possibly the comment on this will be that the symptoms of such"neurotic patients are well known, and they ought to go to a neurologist or a psychiatrist and which takes pride in the fact that it concerns itself with the functional capacitor not to an internist or a general practitioner. In an era of internal medicine, howev organs rather than with mere structural changes and which has developed so many functional tests"of kidneys, heart, and liver, is it not rather narrow minded to limit one' s interest to those disturbances of function which are based on anatomic abnormalities? There are other reasons, too, why most of these"functional"cases belong to the field of general medicine. In the first place, the differential diagnosis between organic disease and functional disturbance is often extremely difficult, and it needs the broad training in the use of general clinical and laboratory methods which forms the equipment of the internist. Diagnosis is the first step in treatment. In the second place, the patients themselves frequently prefer to go to a medical practitioner rather than to a psychiatrist, and in the long run it is probably better for them to get straightened out without having what they often consider the stigma of complex that the aid of the psychiatrist must be sought, but the majority can bs o having been"nervous"cases. A limited number, it is true, are so refractory or so helped by the internist without highly specialized psychologic technic, if he will appreciate the significance of functional disturbances and interest himself in their treatment. The physician who does take these cases seriously--one might say scientifically--has the great satisfaction of seeing some of his patients get well,not as the result of drugs, or as the result of the disease having run its course, but as the result of his own individual efforts Here, then, is a great group of patients in which it is not the disease but the man or the woman who needs to be treated. In general hospital practice physicians are so disease, that they do not pay as much attention as they should to the functiony (a busy with the critically sick, and in clinical teaching are so concerned with trainir students in physical diagnosis and attempting to show them all the types of organic disorders. Many a student enters practice having hardly heard of them except in his course in psychiatry, and without the faintest conception of how large a part they will play in his future practice. At best, his method of treatment is apt to be a cheerful reassurance combined with a placebo. The successful diagnosis and treatment of these patients, however, depends almost wholly on the establishment ofMS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 7 of 11 8/8/2007 10:33 AM organic disease, and in such cases the determination of the causes of the different symptoms may be an extremely difficult matter. Every one accepts the relationship between the common functional symptoms and nervous reactions, for convincing evidence is to be found in the fact that under ordinary circumstances the symptoms disappear just as soon as the emotional cause has passed. But what happens if the cause does not pass away? What if, instead of having to face a single three-hour examination, one has to face a life of being constantly on the rack? The emotional stimulus persists, and continues to produce the disturbances of function. As with all nervous reactions, the longer the process goes on, or the more frequently it goes on, the easier it is for it to go on. The unusual nervous track becomes an established path. After a time, the symptom and the subjective discomfort that it produces come to occupy the center of the picture, and the causative factors recede into a hazy background. The patient no longer thinks "I cannot stand this life," but he says out loud "I cannot stand this nausea and vomiting. I must go to see a stomach specialist." Quite possibly the comment on this will be that the symptoms of such "neurotic" patients are well known, and they ought to go to a neurologist or a psychiatrist and not to an internist or a general practitioner. In an era of internal medicine, however, which takes pride in the fact that it concerns itself with the functional capacity of organs rather than with mere structural changes and which has developed so many "functional tests" of kidneys, heart, and liver, is it not rather narrow minded to limit one's interest to those disturbances of function which are based on anatomic abnormalities? There are other reasons, too, why most of these "functional" cases belong to the field of general medicine. In the first place, the differential diagnosis between organic disease and functional disturbance is often extremely difficult, and it needs the broad training in the use of general clinical and laboratory methods which forms the equipment of the internist. Diagnosis is the first step in treatment. In the second place, the patients themselves frequently prefer to go to a medical practitioner rather than to a psychiatrist, and in the long run it is probably better for them to get straightened out without having what they often consider the stigma of having been "nervous" cases. A limited number, it is true, are so refractory or so complex that the aid of the psychiatrist must be sought, but the majority can be helped by the internist without highly specialized psychologic technic, if he will appreciate the significance of functional disturbances and interest himself in their treatment. The physician who does take these cases seriously—one might say scientifically—has the great satisfaction of seeing some of his patients get well, not as the result of drugs, or as the result of the disease having run its course, but as the result of his own individual efforts. Here, then, is a great group of patients in which it is not the disease but the man or the woman who needs to be treated. In general hospital practice physicians are so busy with the critically sick, and in clinical teaching are so concerned with training students in physical diagnosis and attempting to show them all the types of organic disease, that they do not pay as much attention as they should to the functional disorders. Many a student enters practice having hardly heard of them except in his course in psychiatry, and without the faintest conception of how large a part they will play in his future practice. At best, his method of treatment is apt to be a cheerful reassurance combined with a placebo. The successful diagnosis and treatment of these patients, however, depends almost wholly on the establishment of