Williams M E, Hadler N M
N Engl J Med. 1983 Jun 2;308(22):1357-60. doi: 10.1056/NEJM198306023082211.
Understanding the difference between illness and disease is a prerequisite to the care of patients affected by incurable disorders. Educated palliation in the absence of substantive information regarding this discrepancy is the art of medicine. Because elderly patients often present with several chronic diseases, many of which are irreversible, cure-oriented physicians caring for the elderly are especially vulnerable to frequent disappointments. Multiple influences, such as psychological, social, environmental, and iatrogenous factors, may also substantially limit the possibilities for "total cure." More important, even though many chronic conditions are incurable, the discomfort or disability they produce may be substantially modified. If this concept is not realized and addressed, patients (many of them elderly) with irreversible chronic diseases may receive less than optimal care from physicians seeking cures. Studies need to be directed at defining and quantifying specific interactions between illness and disease and discovering risk factors for chronic disability in the elderly. The degree to which we as physicians can assist the chronically ill may reflect our understanding of human discomfort and our sensitivity to personal distress. If we maintain a purely disease-specific focus, we may have difficulty thinking about strategies to serve the patient. Defining pathologic entities may be less complicated than intervening in the illness of the patient, but the latter constitutes healing.
理解疾病与病患之间的差异是照料患有不治之症患者的先决条件。在缺乏有关这种差异的实质性信息的情况下进行有针对性的缓和医疗是医学的艺术。由于老年患者常常患有多种慢性疾病，其中许多是不可逆的，因此为老年人提供治疗的以治愈为导向的医生特别容易频繁感到失望。多种影响因素，如心理、社会、环境和医源性因素，也可能在很大程度上限制“完全治愈”的可能性。更重要的是，尽管许多慢性病无法治愈，但它们所造成的不适或残疾可能会得到很大程度的改善。如果这一概念没有得到认识和解决，患有不可逆慢性病的患者（其中许多是老年人）可能无法从寻求治愈方法的医生那里获得最佳治疗。需要开展研究来界定和量化疾病与病患之间的具体相互作用，并发现老年人慢性残疾的风险因素。作为医生，我们能够帮助慢性病患者的程度可能反映出我们对人类不适的理解以及我们对个人痛苦的敏感度。如果我们仅仅专注于特定疾病，可能难以思考为患者提供帮助的策略。界定病理实体可能比干预患者的病患情况要简单，但后者才是治愈。
