!!!!

James Tissot, The Beatitudes Sermon, Brooklyn Museum, c. 1890

The eight Beatitudes in Matthew 5:3–12 during the Sermon on the Mount each begins with: ^[2][3]

Blessed are..

• …the poor in spirit: for theirs is the kingdom of heaven. (5:3)
• …those who mourn: for they will be comforted. (5:4)
• …the meek: for they will inherit the earth. (5:5)
• …those who hunger and thirst for righteousness: for they will be satisfied. (5:6)
• …the merciful: for they will be shown mercy. (5:7)
• …the pure in heart: for they will see God. (5:8)
• …the peacemakers: for they will be called children of God. (5:9)
• …those who are persecuted for righteousness’ sake: for theirs is the kingdom of heaven. (5:10)

In verses 5:11-12, the eight Beatitudes are followed by what is often viewed as a commentary—a further clarification of the eighth one with specific application being made to the disciples. Instead of referencing third-person plural “they”, Jesus changes to second-person “you”:^[4]

• Blessed are you when people insult you, persecute you and falsely say all kinds of evil against you because of me. Rejoice and be glad, because great is your reward in heaven, for in the same way they persecuted the prophets who were before you.

R. T. France considers verses 11 and 12 to be based on Isaiah 51:7.^[7]

The Beatitudes unique to Matthew are the meek, the merciful, the pure of heart, and the peacemakers.^[6] The other four have similar entries in Luke, but are followed almost immediately by “four woes”.

 – WIKIPEDIA

Perspective

The Word That Shall Not Be Spoken

Thomas H. Lee, M.D.

N Engl J Med 2013; 369:1777-1779November 7, 2013DOI: 10.1056/NEJMp1309660

During the years when I worked in an academic integrated delivery system, my colleagues and I would frequently discuss patients’ experiences and ways to improve our management of their pain and reduce their confusion as they navigated our complex organization. We knew that anxiety is inevitable for patients facing health issues, but we also knew that there is anxiety, and there is unnecessary anxiety — caused, for example, by the uncertainty that weighs on patients and their families while they await a consultation for a potentially serious diagnosis, or the confusion induced when clinicians give conflicting information. We worked hard to reduce these problems. From a business perspective, it was a smart strategy; from a clinician’s perspective, it was obviously the right thing to do.

So it was a pleasant surprise when I studied the business strategy of a company that assesses patients’ experiences and found that it was based on “helping health care providers reduce suffering.” This strategic framework divided suffering into three types: suffering from disease (e.g., pain), suffering from treatment (e.g., complications), and suffering induced by dysfunction of the delivery system (e.g., chaos, confusion, delays). The company was recruiting me for a senior management role, and my first reaction was that they were interested in the same things as my colleagues and I were.

My second reaction was that the word “suffering” would take some getting used to. I couldn’t remember the last time that my colleagues and I had used that word. “Suffering” made me uncomfortable. I wondered whether it was a tad sensational, a bit too emotional. But on reflection, how could I object to its use? After all, from the perspective of patients, that is what’s going on.

I soon learned that my colleagues and I were not the only ones who avoided the word. As a matter of policy, it doesn’t often appear in our academic journals or textbooks, at least in reference to particular patients. The widely used AMA Manual of Style says, “Avoid describing persons as victims or with other emotional terms that suggest helplessness (afflicted with, suffering from, stricken with, maimed).”1 Public health programs can suffer from lack of funding, and human suffering can be considered (and preferably averted) in the abstract, but patients must generally simply “have” a disease or complications or side effects rather than “suffer” or “suffer from” them.

I asked some colleagues why we tiptoe around this term, which captures so completely what patients endure, and I got a range of responses. One theme was that “suffering” was not “actionable” for clinicians, especially physicians. “Suffering” is too heterogeneous, too complicated. Aware of the irony, one colleague pointed out that too much talk about patients’ suffering might distract clinicians from doing what they could to relieve it.

Physicians need to analyze patients’ problems and address what can be addressed. Thus, there is an ICD-9 (International Classification of Diseases, Ninth Revision) code for anxiety (300.0); you can bill for visits under it, and we have pills that help, too. Most hospitals have a pain service (ICD-9 code 338). We have an increasing number of care coordinators, we have palliative care consultation teams, and there are CPT (Current Procedural Terminology) codes under which their work can be reimbursed. I turn to these services for my own patients when my ability to reduce their suffering is exhausted. But there’s no obvious referral or reimbursement code for alleviating suffering itself.

A second, darker theme was raised by several colleagues: the word “suffering” makes us feel bad. It reminds us that we are powerless against so many of our patients’ problems. And it makes us feel guilty. Suffering demands empathy and response at a level beyond that required by “anxiety,” “confusion,” or even “pain.” None of us see ourselves as people who would stand by while someone is suffering. None of us can imagine ourselves as parts of organizations that tolerate or even inflict suffering in systematic ways.

I hope this doesn’t sound sanctimonious; in fact, I hope it sounds coldly clinical. Our diagnosis was that we avoid the word “suffering” even though we know it is real for our patients because the idea of taking responsibility for it overwhelms us as individuals — and we are already overwhelmed by our other duties and obligations.

For some patients with whom we really identify, of course, we will not rest until we have done all we can to alleviate their suffering. We make the extra phone calls, have the extra meetings, and do whatever it takes to make the system work for them. Those extra efforts define our self-perceptions. But we also know that we don’t do that, and don’t believe we can do that, for all patients. To make alleviation of suffering our job for all our patients feels like trying to fill a bottomless pit.

But what about the organizations for which we work? I was relieved to find that alleviation of suffering is part of the mission statement for the medical school where I teach — and in fact relief of suffering is prominent in the commitments of many health care delivery organizations. That seems right to me. Relief of suffering may be a task too vast to seem real for most people — something on the order of achieving “world peace.” On the other hand, organizations need goals around which to build their strategies; they need clarity about the direction in which they are trying to go. Good organizations have ambitious goals, what would be considered “shared purpose” in sociologist Max Weber’s framework of motives for social action. If an organization has consensus on its overall goal, even if that goal can never be fully achieved, then other incentives (financial and otherwise) can be developed to drive progress in the right direction.2

If good organizations have ambitious goals, great organizations are effective in pursuing them. They close the gap between their mission statements and their operations. They find ways to measure what matters and organize themselves to improve their performance. They track and manage their progress toward those goals with the same discipline that they apply to their financial performance.

In truth, I’m less interested in the words we use than in what we actually do, and what we organize ourselves to do. Collectively, we should not shy away from work that can never be completed. For our organizations, relief of suffering does seem like the right goal, endless though the work might be.