Welcome to the latest essay in our “On Healing” series, where Dr. Wayne Jonas explores whole person care and the deeper dimensions of healing.
“You’re the best doctor I ever had,” a patient wrote to my colleague Bill after he retired. He had cared for her since her college years, delivering four babies, helping her through crises, and attending the funeral of one of her children. But when Bill asked what she meant, she didn’t mention any of those moments. She said: “You were the first doctor who ever asked me about my daily life. Then I really saw how you cared for me as a person.”
Her answer has stayed with me because it says something essential about suffering and healing. In medicine, most of what we do is still organized around finding a diagnosis, naming the disease, and matching it to treatment. We don’t always think about alleviating suffering, which includes the threat to someone’s life, integrity, relationships, hopes, and even their sense of who they are.
My colleagues Bill — William Phillips, MD, MPH — and Thomas Egnew, EdD, have explored a dimension of healing often not addressed in medical practice: the transcendence of suffering, which they say is at the heart of healing. I wanted to explore what they meant by saying healing transcends suffering. Their answers helped clarify something I have seen throughout my career as a family physician: When a cure is not available, not enough, or not even the right answer for the problem, healing is still possible.
Suffering is not pain
Early in our discussion, I asked both Phillips and Egnew to define suffering as distinct from pain. Egnew drew on Eric Cassell’s classic insights that suffering is the distress that arises from threats to the integrity of personhood — how you identify yourself as a self. In other words, suffering is not simply what hurts. It is what makes a person feel they can no longer be who they have been or who they hope to be.
This distinction matters because medicine often collapses disease, illness, and suffering into a single entity. But these are three distinct things, and healing comes to them in different ways. Disease is a physical problem of structure, function, or biochemistry. It is the part of dysfunction most amenable to cure, and if cured, healing often spontaneously follows. Homeostasis returns. Illness is the lived experience of what is wrong — usually pain or emotional distress. It may or may not accompany disease. Healing of illness involves helping to reduce these symptoms, with or without a cure.
Suffering, however, is more of an existential or spiritual problem. It is the threat the condition or dysfunction poses to identities, roles, relationships, meaning, and one’s future. Disease, illness, suffering — those realities overlap, but they are not interchangeable. When we confuse them, we risk missing the patient’s deepest need or treating them in the wrong way.
Phillips and Egnew have both spent years teaching physicians how to diagnose and distinguish between disease, illness, and suffering. Yet medical education still devotes enormous effort to the diagnosis and treatment of disease, only some to illness, and almost none to suffering. My colleagues’ research with medical students showed that trainees were not taught to identify or manage suffering and did not see this modeled consistently by their teachers. To help fill this gap, they have developed a comprehensive model for healing suffering. It involves a process that supports the transcendence of that suffering.
Healing is larger than cure
One of the most important corrections that Phillips made in our conversation was this: healing and curing are not opposite, and cure is not the whole of healing. A person can be cured and still suffer. A person can remain chronically ill and yet heal their suffering.
This is especially obvious in chronic pain, multimorbidity, trauma, and the many conditions in which biomedical treatment has only limited power. In such cases, the relentless hunt for a cure can narrow our vision and worsen the illness experience. Bill put it bluntly: The healing model is the larger, all-encompassing model, and cure is one small subset within it, albeit the subset where most of the money in medicine is spent.
That is why Phillips and Egnew’s work on suffering matters so much. Their comprehensive clinical model of suffering asks clinicians to look across four axes — biomedical, sociocultural, psychobehavioral, and existential — and to notice how suffering may arise in symptoms, function, roles, relationships, emotions, thoughts, personal narrative, and worldview. It is a reminder that when medicine has less to offer at the level of physical cure, we should not do less. We should widen the frame.
Suffering that lives in the body
I asked another question: Does the relationship between suffering and disease go both ways? We speak often about how disease leads to illness and suffering. But does untranscended suffering lead back to disease? More hopefully, does the relief of suffering lead to measurable physiological change and cure?
Bill pointed me to the most severe end of the spectrum: loss, depression, and suicide. Suicide has the hardest biomedical outcome there is — death — and we see it follow from suffering that has no diagnosable clinical depression underlying it. The loss of a child, the end of a marriage, or the shattering of a life’s purpose after trauma are not diseases, but they can produce fatal outcomes. I added what I have seen in working with veterans: The soldiers who came home from deployment without physical injury developed what we now call “moral injury,” an existential rupture in their sense of who they were. Many, many of them died by suicide even while under medical care. Even without diagnosed depression, their suffering proved deadly.
Bill then described a large and underappreciated group of people: patients with chronic unexplained symptoms — persistent abdominal pain, fatigue, diffuse musculoskeletal complaints — who cycle through specialists, accumulate diagnoses, get multiple ineffective treatments, and are never quite better. Most of the burden of these conditions, he pointed out, falls on primary care providers. The conditions do resolve, or at least become manageable, through a sustained relationship with the primary care provider and attention to the person as a whole and by helping them tap into their inherent healing capacity.
Chronic low back pain is the best-studied example. In this condition, the patient’s experience of illness and suffering frequently cannot be explained by the degree of structural disease. One of the most valuable things a physician can do is help the patient avoid unnecessary treatment. But while the medical encounter can make things worse, a healing relationship characterized by curiosity, presence, and continuity can make things better. Supporting the patient with wellness and self-care practices often helps improve the pain, even though those practices are not specific treatments for pain.
This brings me to something I have been exploring for years: the so-called placebo effect, which I prefer to call the meaning effect. The anthropologist Dan Moerman and I argue that “placebo” is an incorrect term; what “placebo” responses demonstrate is that meaning making can produce real physiological change. When suffering is reframed and a patient feels genuinely seen and accompanied, something moves in the body as well as in the mind. That is not mysticism. It is the bidirectionality implied by Phillips and Egnew’s whole-person model. The body and the self are not separate systems, and healing at the level of personhood can reach down into the tissues.
What does transcendence mean?
Tom Egnew made the point that transcending suffering does not necessarily mean erasing it or rising victoriously above it. It means the distress no longer has the same hold. He used the example of a widow or widower who speaks of a deceased spouse with anguish and emptiness at first. Later, they can speak with warmth and gratitude about the years they shared. While the loss remains, its meaning and the spouse’s relationship to it has changed.
Phillips describes this process as helping patients edit their own narratives, revising them so a new meaning can emerge. I found myself pushing on the positive side of that process. Transcending suffering does not only mean less distress but an increase in wellbeing, connectedness, and wholeness. As Phillips put it, “It’s peace, not dominance.”
The clinician’s role
Both Egnew and Phillips shared observations on the clinician’s role and its limitations. Egnew observed that healing cannot be forced. Phillips added that while you cannot command healing, you can commit to caring, and that caring increases the likelihood of healing happening.
That commitment is not trivial. For a patient who is frightened, isolated, or carrying years of unspoken distress, it matters profoundly to hear, in word or in presence: I am with you. I am listening. I will walk this journey with you. Even before anything like transcendence occurs, that kind of care can relieve suffering.
It also builds the kind of continuity that makes deeper healing possible. Phillips said that when patients describe meaningful continuity, what they often mean is simple: The doctor and I have been through a lot together. Egnew teaches residents to begin each visit by referring to something from the last encounter and to learn one new thing about the person every visit. These may seem like small acts, but they build trust. When life becomes heavier, the relationship has a foundation on which to stand.
Egnew has formalized some of this into a practical tool he calls the Agenda-Setting Algorithm — a structured approach to opening each visit. Before diving into the presenting problem, the clinician spends a few moments establishing rapport and then asks, “Before we get into that, is there something else you would like to discuss today?” This approach reframes and widens the conversation to focus on the person.
As the patient lists concerns, the clinician can help prioritize them. The last step is simply to keep asking, “Is there something else?” until the patient runs out of new concerns. What this does is ensure that the patient’s sense of what matters most can shape the clinical encounter and the treatment plan from the start.
That is what the patient’s words to Bill were really saying. The thing she remembered was not rescue in a crisis but being known in ordinary life. In the end, that is what whole person care feels like.
A larger purpose
The more I explore the issues around healing, the more convinced I become that medicine has overbuilt itself around the narrower task of cure and underinvested in the larger work of relieving suffering.
Cure matters, and when it is available it can be a blessing. However, most human illnesses do not fit neatly inside the frame of cure. There is no single treatment. There is no magic bullet, even though we often pretend there is, claiming we are using “good” evidence. Much of what patients bring us is chronic, relational, existential, and embodied in ways our conventional categories and “this for that” approaches do not fully capture.
This is one reason addressing suffering matters so much to clinicians. Phillips and Egnew both spoke about the moral distress clinicians experience when they are trained to practice in a particular way and are then thrust into systems that make it challenging to offer time, continuity, curiosity, and presence. Reconnecting medicine to the work of relieving suffering can help clinicians too.
What would it mean to take that seriously? It would mean paying attention not only to disease metrics but to the conditions that allow trust, meaning, and healing to emerge. It would mean seeing continuity not as an administrative convenience but as part of the therapeutic intervention. And it would mean remembering, as Phillips’ patient reminded him, that one of the most healing things a doctor can do is ask about what matters for them.
For Further Reading
- Egnew TR, Lewis PR, Myers KR, Phillips WR. Medical student perceptions of their education about suffering. Fam Med. 2017;49(6):423-429.
- Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York, NY: Oxford University Press; 1991.
- Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170-175.
- Ventres WB, Stone LA, Shapiro JF, et al. Storylines of family medicine V: ways of thinking—honing the therapeutic self. Fam Med Community Health. 2024;12:e002792. doi:10.1136/fmch-2024-00279.Phillips WR, Uygur JM, Egnew TR. A comprehensive clinical model of suffering. J Am Board Fam Med. 2023;36(2):344-355. doi:10.3122/jabfm.2022.220308R.
- Egnew TR, Phillips WR. Transcending suffering. In: Ventres WB, Stone LA, Shapiro JF, et al. Storylines of Family Medicine V: Ways of Thinking—Honing the Therapeutic Self. Fam Med Community Health. 2024;12:e002792. doi:10.1136/fmch-2024-00279.
- Egnew TR. The art of medicine: seven skills that promote mastery. Fam Pract Manag. 2014;21(4):25–30. PMID: 25078009.
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