1H

40. Bjo:rrum OJ Imrnunocn.:nnc .. ' .""""il':oI"'" of mctIIhnoroe P"''''''''' " me

lIIodial _y",,,II """"""is p""-"'d on ;1III'IIU",,,,,,,,,ipilaliollon . BIO
dIim 8iGpbys ACUI 1977; 472;J)S-9S.
41. BjeInIm OJ. 8b.II<d.i S. imInunorlecll'Clpborc:si.s of membrane ....
Ieias - seneral priJOciples. Sc:and J 1_.... ISuppil 10:2119-301.
42. Itiefel V. J<igcr S. M""IIcr-b:khanlt C. CompcIilfvc co,ymc-liDked 'ID/IUI
naISSa)' for Ihc quantiuIioII of pIaIdcIassoci.ltcd immunoglobulins (Ig(i.
IgM. IgA) IIIId complemc1ll (C3c. C3d) with poIycklul and moaacklul
n:qcnIS. Vox SaD!! 1987; 53:151-6.
43. HugoF. krimcrS. BIIatdi S. Sc:asiIiYe EUSA forquanlilaliog Ih<tc:nniaal
_blanc CSb-9 and lIuic!pIIase SCSb-9 complex of human
J ImaumoI MeIbods 1987; 99:243-51.
44. Sachs L_ Applied SUlisIics: a IwIdbook of 1I:ChaiqDc:s. New yOlt: Spriaecr.
Valac. 1982;549-55.
45. Koski a.. Rarnm LE. Hammc:r Of. MM. Shin MI.. CyIOiysi:s of
IIIIIIdeaIcd cdJs by c:ompa.:.-= c:eII ..... dispIay5
Proc NatI Acad Sci USA 198.3:
46. UmpbcU Alt. Morr'" tiP. lIIIIibudic:; cIcmonsnte pruIettiooI
of poIJ'I'I"ClI'I'Ibu.:lear ieuk""Y"'" ag...... Noorun! 19&5:

47. Camey Of. Koski a.. Shin ML. ElimiaMiaa of IC:mIiRat _nplc:......a iDler.
mcdiaIes frem rhe pW;ma membdne of IIIICIael cells: Ibe nIe of disap
pearance differs for cdl$ carrying CSb-7 or CSb-I or a IIIixlun: of CIb-8
with a limited DIIIDiIcr of J ImaumoI 1985; 134:1804-9.
411. Mcqaro BP. CampbeU AK. The of ........
lcuI::ocyIe$ from sublylic: compIenIeet aaact is by ia iIIIra
ceIJuIar fu:c calcium. Biocbem J 1985; 231:20S-8.
49. Carney Df. HatDI1II<Z Of. Sbin ML. ElimiIIaIioII of II::rmiDII
c:ompIeae:s ill !.be plasma _baaeofIlUCIc:aIed cdb.: iDIIuaII:e ofeQI'IiCId.
IuIar ea'+ IIIId assoc:iIIIioD wiIh cdIuJ.v cr+'. J 1916; 137:263
70.
50. WiedIIa T. Es_cr. Sims PI. On die -=iIIaism by wIIicIt ,.
JIRIIeins u-pIaIeIa pn1IbI...o-lICIiYity. J BioI CIa:m 1916;
261:1458792.
SPECIAL ARTICLE
THE PARADOX OF REALm
ARTHUR]. BARSKY, M.D.
Abstract Although the collective health of the natiOn has
improved dramatically in the past 30 years. surveys reveal
declining satisfaction with personal health during the same
period. Increasingly. respondents report greater numbefs
of disturbing somatic symptoms, more disability, and more
feelings of general illness. Four factors contribute to the
discrepancy between the objective and subjective states
of health. First. advances in medical care have lowered
the mortality rate of acute infectious diseases, resulting in
a comparatively increased prevalence of chronic and de
generative disorders. Second, society's heightened c0n
sciousness of health has led to greater self-scrutiny and
O
UR society currently devotes enormous amounts
of time, money, and effort to preserving our
health and obtaining medical care. But in one sense
that pursuit is proving paradoxical: the substantial
improvements in health status have not been accom
panied by improvements in the subjective feeling of
healthiness and physical well-being. Instead, people
now report higher ralt:s of disability. symphJms, and
general dissatisfaction with their health. As they pro
vide clinical care. shape health policy, and deal with
the public through the media, physicians ncC"d to be
aware of this gap between objective health status and
wdl-Ix-ing.
THE NATION'S IMPROVING Ht:ALTH SIATUS
Our nation's ('ulkt'!ivc health i.s ('xceilem, "lthough
sizahlc minorities !C.'main ",hose ht'ahh .IlUS is lin
worse. Medical care, prevt"ntive medi(inl". ;11\<1 health
promotion have made 'l'r<:at advances. especially sinc("
I he late 19605 . .-\ c.:hild born in 1984 coulrl t:xpt'ct to
Iiw: to the age of 74.7 years. Lift" expectancy is greatest
Ii" while wnfl)(,11 (7R.B YI".:us) and 10w("St I; If l10nwhite
I-n"" the Pnchiall'), ServIce. M_'hu'CIU General Hu"pIIOII. """ tho: Oepan.
_....:11 .. p,.\"d',:i ,dry, !b:1'\.ud Sct\ll.'L KoSh'ft. ft,"""m rc'4oestS ,tt
B.41.!J.:) ar G:1Jc!ra1 t Anlbut."b)fY l Oii': (.'tfJtt:'r "':ti7..
J'nut Sf Bsntcm MA 02114.
----------.---......__._._..._..._...NE.W,.EN.GL8blD..lD.lll:UiAL
--.-..---...----..--...-.......___................._........T11E.P..ABAD.OX..QE..l:J
BY ... -_._.____....B.ARK.S.Y....._........._.................. Copyright .318...._.......
ONE TIME PERMISSION GIVEN TO ANTEATER PUBL. TO REPIIDIT BY NEW EN(
433
an amplified awareness of bodily symptoms and feelings
of inness. Third, the widespread commen:iaIizati of
health and the increasing focus on health issues in the
media have created a climate of apprehension. insecurity,
and alarm about disease. Fmaly. theprogressiverneckaJ
ization of daily life has brought unrealistic expecta.tioiIs of
cure that make untrealabie infirmities and unavoidable ail
ments seem even worse. Physicians should become more
aware of 1hese paradoxical consequences of medical
progress so that they do not inadvertentty contribute to a
rising public dissatisfaction with medicine and medical
care. (N Engl J Med 1988; 318:414-8.)
men (67.1). Within these extremes, nonwhite women
live' longer (75.3 years) than white men (71.8).1 From
a historical perspective, the increases in longevity are
indeed impressive. In 1900 the life expectancy at birth
of the average American was 4-7.3 years. Over the next
50 years, we made remarkable progress, but the gains
of the past 30 years havcbeen truly stunning. Life
('xpcnancy in 1984 wa.<; 3.8 years longer than it had
been in 1970, only 14 years earlier, and 6.5 years long
er than ill 1950.'3
These gains reflect declining mortality rates. Age
adjusted death rates have dropped by one third over
the past thl'('e decades, from 8.4 deaths per 1000 peo
pk in 19.">0105.5 deaths per 1000 in 1984.' Aud aI
age-adJusted death r:ues for cancer have reo
mained fairh' stahle, they have declined lor 10 of the
15 1Il0S[ frt'tJUt'l1I l:aUSl:.s of dt'.llh, including heart dis
cast:. stroke, diabetes, and peptic ulcer.
lnraut mortality, another measure of collective
health status, has also declined with each 5ucreeding
year, Ihough a wide disparity persists betwt:t"n the
riUI'S I(,r whitt: and nonwhite infants. Between 1965
and i
l
lH2, iub.lIt-mortality r,u('S were balvext. SilllX'
19fd, when the U.S. infant-mortality rate was 24.7
deaths per 1000 live births, the rate has fallen quk.kly,
A P"""'III per Ott .I\'t"rage. In 1982 inf;ult
mortalily dmpPe(i to , 1.5 dealhs oer 1000 live births.
Barby, A.J. (1988). The paradox of health. New
Emdand Journal of MediCine, 318, 414-418.
Permission to reprint granted by the publisher.
.." 1742k
VIA THE CCC.
I
THt: i'AR....UOX OF HEALTH - BARSKY
"I. 318 No, i
r
, I
,d by 1984 it had fallen to 10.6. (The pace of the
ecline has slowed since, however.)
Modern biomedicine has enhanced our ability to
redict, detect, diagnose, and treat the array of dis
lses to which human beings are heir. According to
lle estimate, in 1928 we had effective treatments or
reventive measures for 5 to 10 percent of the 360
lost serious diseases. By 1976 this figure had risen to
etween 50 and 55 percent.
4
More recently, advances
medical care have been matched by advances in
reventive medicine, health promotion, and self-care,
s an increasing proportion of morbidity and mortal
y has become behaviorally determined, many people
ave made notable changes in their health habits and
fe styles. Our considerable success in combating car
iac disease in the past 20 years serves as a good exam
Ie. More than half the gains in this area have been
ttributed to life-style changes - reduced dietary in
tke of saturated fats, decline in cigarette smoking,
'eigh t loss, and physical
THE DECLINE IN WELL-BEING
During the past 20 to 30 years, people's subjective
:nse of healthiness has not kept pace with improve
lents in health status; indeed, it appears to have de
ined. According to nationwide polls and community
lrveys, the proportion of Americans who are satisfied
ith their h!:'alth and physical condition has fallen
om 61 percent in the 1970s to 55 percent in the
tid-1980s,6
People report more frequent and longer-lasting epi
>des of serious, acute illness now than they did 60
=ars ago, despite the introduction of antibiotics dur
tg the intervening period. In community
lrveyS in the 19205, the average respondent reported
82 episode of serious, acute, "disabling" illness per
ear, Asked the same question in the early 198Os,
mericans reported 2.12 such episodes per year.
3
In
:Jdition, nowadays i,a}' that l'ac:h episode of
isabling illness lasts longer - 19 days on the average,
; compared with 16 days in the 19205.
3
More studies show the same trend. In 1957
rid 1976. l;trge nationwide samples of adults were
Iterviewcd about their health. Asked about common
>rnatic symptoms such as dyspnea, palpitations, and
ain and whrlher they felt healthy enough to do the
lings thrv wanted ro do, men and women both re
orted more ill healtJl in 1976 than thr\' had in 1957.'
'here was .tlso a decline in the of pooplc
ho reported no symptoms al all, or almost none.1
Anothrr recent trend is toward !uuger periods of
isability episode of illness. In surveys from the
lIe 1950s through the late 19705, including the Na
onal Health 11llt"rv1ew Sun'('Y, buth men and WOmf"ll
isclosed substantial increasf'S in disability.8,11 The to
II numhers of days of restricted aCli\'ity and days in
cd li";r an:'" ;1110 ('hroni,' h.l\"I" risl'n sharrh.
nd th(' pmp<,rtion of peopJr whn reporl a permanent
Hal disabililv has increased.
I
:.'
Illlapi long;itudinal,n'T':: ,I"!:J !ik( is
'r3chcrous. since the data arc' suh,el't 10 numt'TOIiS
uncontrolled confounding factors. In addition, meth
odologic make comparisons difficult. Ob
viously, many rxplanations could be given for such
widespread phrnom!:'na. Nonetheless, there is a con
sensus that one of the salient factors is a progressive
decline in our threshold and tolerance for mild dis
orders and isolated symptoms, along with a greater
indination to view uncomfortable symptoms as patho
logic - as signs of disease. Coupled with this has been
a readiness to adopt the "sid" role, to seek medical
care for isolated symptoms, and to acknowledge to
others that we feel ill. The standard we use for judging
our health appears to have been raised, so that we
are more aware of - and more disturbed by - symp
toms and impairments that previously we deemed
less important.
THE PARA.DOX OF HEALTH
We have seen that our subjective feeling of healthi
ness and physical well-being has decreased even
though there have been major advances in our actual,
objective health status. What factors explain this
paradox?
Epidemioiogic FlICtors
Many of the medical gains have come in the treat
ment of acute and infectious diseases. Less progress
has been made against the chronic and degenerative
ailments that come with longevity. Thus, we have
in effect exchanged acute, life-threatening illnesses
that arise earlv in life for chronic and disabling ones
later on. The people saved from untimely and sudden
death from pneumonia, endocarditis, tuberculosis,
and childhood infections now live long enough to
acquire their burden of osteoarthritis, cataracts, dia
betes, and the rest.
Thus, we live longer, but a greater proportion of our
life is spent in ill health. In addition, people with
,hr(lnic disf"asl'!I survive longer than formerly because
our improved medical care, aJthough it does not cure
the disorders, retards their progression and also ex
tends survival by curing the superimposed acute infec
tions that in thl:' past had been terminal.
8
Thc- result of
lengthening lif!:' is to increase the proportion of the
:popular ion aOliclrd with thes!:' chronic diseases. This
has trrnH'O lhe- "failurr of our SlI(T('SS" IU - tht'
pht-noml'non wherrby som!:' dis!:'.ases become more,
ralhn thiln ils';. prC'vaknt as a result of medical
ad\an,t-s.
The Heightened Awareness of Health
He.alth has taken on overriding importance for
many Anu'ricans. In nationwidf' polls, 46 percent of
the resJxJll(knls .. "'good health" as the grcatt-st
singlt- sourc(' or happiness, ahed of any alternativt:,
induding "gr('at wt:alth" or personal satisfaction
rrnm ac("nmplishm,nrs.-
6
Certainly, We do spnld ilion: and IIlUIT (.1\
hrahh. In 1(170 our 100ai national t"xpt'nditurcs f()r
h,';)lIh ('an' wen' $75 hill ion, alld by 1986 Ihe hill h;.d
dillli)('d to :HVi hillion. j I WheJl til<" are ('m"
434
Wi
FrI>. 18. 1988
reeted for inflation, the same prt-cipitous rise is evi
dent: the per capita outlay for health care, in constant
dollars, has gone from S292 in 1970 to S431 in 1986.
11
Equally important, the proportion of the gross nation
al product devoted to health has also risen - from 7.4
percent in 1970 to 9.1 percent in 1980, and 10.8 per
cent in 1986. II
The emphasis on health is also seen in the strenuous
pursuit of the "healthy life style" and in widespread
attempts to reduce risk factors. Eighty-seven percent
of adults say they have attempted to make at least one
healthful change in their lives. Sixty percent say they
have adopted a more healthful diet, 46 percent have
tried to lose weight, 45 percent have exercised more,
and 44 percent say they have tried to control stress.
12
Health has become a popular avocation: in 1984,4 of
the top 10 hard-cover, nonfiction best sellers dealt
with diet or fitness,13 whereas in 1965 none did.
14
Health resorts are increasingly popular vacation desti
nations, with a l2-fold rise in the number of guests in
five years15; health fairs now rival boat and car shows
in attendance. 16
There is a growing fascination with diet, nutrition,
and weight loss. Surveys show people deeply con
cerned about the fat, salt, fiber, and sugar content of
their food; they are interested in vitamin and mineral
supplementation, most recently calcium. The fear of
obesity is so strong that it has affected fourth-grade
girls, 80 percent of whom are afraid of gaining weight
and feel they weigh too much.17 Even some infants
have been placed on overly stringent diets by parents
unduly concerned about childhood obesity.18
The physical-fitness boom is another manifestation
of our preoccupation with health. It is widespread
among both women and men: one third of Americans
sa)' they engage in regular strenuollS exercise,6 a group
that includes more than 31 million serious joggers, 19,20
26 million regular swimmers,21 and millions more who
take aerobics classes and lift weights. Of those who
participate in vigorous physical conditioning, most
do so for reasons of health.
19
This drive for physical
fitness fuels all ec.;onomic juggernaut involving exer
cise videotapes, health clubs, and personal fitness
instructors.
Although our society's fascination with health has
had many substantial benefits, it has at the same time
eroded the sense of well-being. Paying increased at
tention to om"s body and one's health (ends to make
one assess them more negatively, with greater feelings
of ill health. Several investigations have shown (hat
bodily awareness, self-consciousness, alld introspec
tion are associated with a tendency to amplify somatic
svmptoms and to report being troubled by more symp
toms.
22
-
2
+Studies in perceptual and experimental psy
chology suggest that, in general, the more aware peo
ple ar(' of their ('haracteristics and attributes. the more
negatively they assess them.:.!4 This appt'ars to be par
ticularly nut' for physical attributes. bodily sensa
tions, and p<'rceptions of health.
The cui,,!,;:! -!ima:t' wday p""rk II) pay
435
more attention to their hodies, their symptoms, and
their state of health. Thi6 increasing scrutiny itself
amplifies discomfort and dysfunction and results in a
more.negative appraisal of one's health.
The Cammerciallzlrtlon of Health
Health is industrialized and commercialized in a
fashion that enhances many people's dissatisfaction
with their health. Advertisers, manufacturers, advoca
cy groups, and proprietary health care corporations
promote the myth that good health can be purchased;
they market products and services that purpon to de-
liver the consumer into the promised land of weUnesa.
A giant medical-industrial complex has arisen,25 com
posed initially of for-profit health care corporations
such as frec-standing ambulatory-surgery centers,
free-standing diagnostic laboratories, home health
care services, and of course proprietary hospitals. But
the market is so lucrative that the products of the
medical-industrial complex now range all the way
from do-it-yourself diagnostic iits to "lite" foods, from
tooth polish to eye drops, from health magazines to
Medic-Alert bracelets, from exercise machines to fat
fanns.
Each producer tries to convUice the public that
something is dangerously wrong, or about to go
wrong, and that immediate steps must be taken to
remedy the situation. An indifferent public is first gal
vanized into becoming a market of alarmed consum
ers by constant reminders of myriad threats to health,
and then convinced of the need for more and more
products and services to protect them. In the process,
deep-seated fears about disease are mobilized, and in
securities about health and longevity are intensified.
As a result, many come to feel less secure about their
health, more worried about the possibility of disease,
more absorbed in trivial symptoms.
The mass media have placed an increasing empha
sis on health, sometimes amplifying the public'S sense
of somatic vulnerability and apprehension of illness.
With all the publicity devoted to Alzheimer's disease,
for example, it has recently become necessary to reas
sure people that forgetfulness is most often normal.26
Toxic shock syndrome is another example of the way
in which this "medico-media hype" 27 can produce un
warranted anxiety and fear.
28
.
29
In the competition fOT
a wider audience and more attention, for more viewers
and readers and listeners. medical hyperbole is all too
frequently invoked. Health hazards are sometimes ex
aggerated, factual inacC'uracies may be relayed to the
public, and preliminary rt'search findings art' touted
as breakthroughs and presented without appropriate
cautions.
This medico-media hype, promulgated by media
people, advertisers, public relations experts, manufac
turers, and even some members of the health profes
SiOIlS, induces a cultural climate of alarm and hypo
chondria, undermining feelings of well-being. It is
harder to feel confident about one's health when sen
sations and ont' had assumt-o IfI be trivial
-117
rot :l18 No, 7
THE PARADOX OF HEALTH - BARSK Y
r:re portrayed as ominous, of autologous blood transfusions are prescribed to im
Dre unrecognized or Feelings of prove athletic prowess, stimulants are given to sup
ill health and disability amplified ache press normal fatigue or sleepiness, sex-change surgery
:s though[ to merit attention, is performed in anatomically normal trans.sc:xwr.b, iUld
:nay be prodrome of a malignant when we of course are tubal ligations, vasectomy, and a
ire told that every mole and wrinkle desetVes host of new lechniques to intervene in the normal
of fenilization, conception, and intrauterine
fhe Ihdlcallzatlon of Dally Life
development.
Medical care plays an increasing part in daily Hfe. makes it possible to relieve many
!\lthough this results in great gains in our hwth sta conditions that could not be remedied be
:us, it also helps to diminish our sense of weJI-being, fore, but it has a side effect. It leads pe0
naking symptoms and disabilities that not curable ple to believe that more and more of their discomforts,
ieem than they used to seem, infirmities, and impairments are curable. Medical tri
Americans consult physicians more than umphs intimate a world in which whatever ails us can
- for a broader range of problems and for be treated away. This creates a problem of rising ex
ess serious conditions. In 1982, the mean number of pectations: having come to imagine that somewhere
.isits to the doctor pu person was 5.0. I By COl'Itrast, in there is a treatment for almost everything that ails us,
:he 1930s citizen 2.5 visits.
30
One we experience symptoms and residual im
:eason for this change has been an increasing willing pairment as insupportable - as a an injus
less to go to the doctor with minor symptoms and tice, a failure of medical care. 11IDess seems all the
Jenign illnesses, such as musculoskeletal and sinus more disturbing because we think it need not have
:omplaints and gastrointestinal symptoms.' At pres at all. Because we expect so much from
:nt, in 30 to 60 percent of the visits to primary medical care and preventive medicine, and because
:lhysicians, no serious medical condition is found to we have invested so much in them, we become frus
lceount for the patient's symptoms.
31
Among the out trated and disappointed by medicine's achievements,
:latients cared for in such settings, 25 to 40 substantial though they are. Incurable ailments and
lave no serious medical diagnosis.
31
Infections of the trivial infirmities alike seem more noxious and dis
:1pper respiratory tract now the most common sin abling once they are thought to be avoidable, unneces
disorder in general medical prac sary, or remediable.
34
jce.
32
The threshold for seeking medical attention has Studies of obesity and disfigurement illustrate well
liso been for more serious illnesses. For exam this effect of unfulfilled expectations on well
::lIe, women with symptoms of urinary tract infection being. Overweight people who try to reduce are more
Ire estima ted to be five times more likely to seek medi dysphoric than people of the same weight who have
:al attention now than thev were in the 1920s.
3
accepted their condition and are not trying to lose
Besides consulting doctors for less suious condi weight.
39
The belief that normal weight is attainable
:ions, patients now consult them for conditions that seems to be disturbing than not aspiring to thin
were previously considered unsuited to medical treat ness in the first place; admitting a dislike of one's size
St"Vt"ral observers have noted (and a and trying hard to alter it makes it more intolerable.
:listorical trend toward dMant and un Studies of facial disfigurement show something simi
jesirable forms of behavior as diseases, rather than lar: minor deformities cause as much or anguish
:rimes or religious transgressions,:'!3-35 Examples of than defects too major to be corrected.
38
On the othu
'his medicalization of behavior include alcoholism, hand, the most grossly deformed or pe0
irug addiction, child abuse, and some forms of im ple, for whom cure was never a possibility, have often
;ulsive \'j!..lience,36 Physicians are also asked increas learned to accept their defects,
ngly to "treat" physical conditions that are not dis
CoNCLUSION
:ases in {he traditional sense - baldness, unattractive
arial fra{ures, breasts that are too large or too small, must be alert to the paradox of medical
dtigue. and jt"{ lag. With an estimated 500,000 cos progress. .\, clinicians and teachers, we need to
netic operations performed in the United States in point out that there is no one-to-one correspondence
1986, plastic surgery is one of the fastest-growing between objective health status and the subjective pu
nedical speciaities.
37
In addition. 80 percent of those ception of healthiness. In shaping public policy, ad
Nho go to orthodontists now do so for cosmetic ministering programs, and dealing with the media,
:IR
physicians musl bear in mind the negative side effects
The mental health mon'mem has brought a greater that can accompany 3n intensified emphasis on health
'ange of emotional distress and maladaptive person and heightened expectations of medical care. Other
tlilY STyles to psychiatric artention, along ",;th dif wise, when massive health care expenditures, strenu
ill s('xual pert():';n,.n{;(, st"lf-asse.f1ioll. :wel ous f'fforts 3: risk-factor mod ific3til.'m, and conscien
)cwpational functioning, Finally, medicint" 'has ac tious visits 1(, the doc lor fail to enhance well-being,
lllirrd In!' ('apabilitv of "In'alin!!:" perfC'Cdv normal disenchantmt'IH and disillusionment with medical
:haracteristics and tuncUUIIS, Anabolic steroids and care aloe li;"',';:_ it, gr"w,
\
436
III!
h h. IK. 1'1118
As a society, must be careful lest our mr-dical
advances make us all the more uncomfortable with the
afflictions that remain unconquered. Physicians must
be careful not to foster this way of thinking or uhi
mately to accept blame for it. We need not curb the
pursuit of health, but only pay more attention to culti
vating subjective feelings of wel.J-being as well.
Ib:n::RENcEs
I. Depanmenl of HeaIlh and H_Sc:mc:es. Public HcaIdI Senicc. HeaI!b.
UDiu:d StalC:S; 1985. WasbillgIDo. D.C.: Gow::ramr:m PriAIiIII Office. 1985.
(DHHS 110. (PHS) 86-1232.)
2. Roprs DE. BIcncIon RJ. The c:IIIapIg A:me:riaul Matdl ........: sumaimes
IhiDp FI beDa:. lAMA 1977; 237:I7J0-4.
3. Shcncr E. Bedside 1DIIIIIII!f'S: die IIVUbIed hisIory of doclOl$ aM patic:ar:s.
New Yori:o SimoD &: 198.5.
4. Bco::sc. P8. Oae I!uI!idRd ....... of Amc:Ii<:;m ima1IIII mediciDc:: a view fiom
!be imide. ADD lnrenl Mod 1986.; 105:436-44.
5. Goldman L. Cook EF. Decliae in is<:bemic heat diIIease IDOI'IIIiry -= ""
nalysis 01 !be COII1pII"IIive dfoca of mr:dicaI iaIa..-ioG aM d-.=s ill
Iifaryk:. ADD Imcm Med 1984; IOI:Jl2S.36.
6. Hans L. IIIsidc AmcricJI. New York: ViI.aF Boob, 1987.
7. Vaoff l. Douvan E. F\IlLa ItA. The inaer Amcric:aa. New York: 8asic
Boats, 1981.
8. Vatnggc LM. Loagcr life baI -ills balch? Tlalds ill Matdl IDd
DICIrWity of middle-qcd and Mihal. Mcm Fund Q 1984:
62:475-519.
9. CoI'IIel: A. Bw.:beI M. Oisabilily 1I\e9ds ill die United S....,. populatioa
1966-76: analyses of rrpanAId causes. AmJ Public Hca11111981; 71:464-71.
10. EM. The failures of succ:=ss. Milballt Mcm I'IIDd Q 1977; 55:3
24.
11. Ginzbes"g E. A bard Icoi III COSt CCIIIlIiJImenI. N J Med 1987;
316:1151-4.
12. GuriD J. The us Jel1I!r4lion. Am Hc:aItb. Oc:lober 198.5:40-1.
13. Toufe:r.is A. The shape of Ihe naim. Time. Oacber 7. J98.5:60.
14. The world almanac: and book of f-., 1966. New YoIt:: New Yori: World
Tdegr.am Corp .. 1966:512.
15. Toufis A. Sbal<c a leg. Mrs. Plushboaom. TUDe. Juoe 2. 1986:78.80.
16. Greer WR. Hcallil fairs mo.., imo die mainstJeam. New YoIt: Times. April
2.1986:CL
17. bslow J. Fowthgrade guls Ibcse days p:>nde.r weighty 1JIII1'Ieni. Wall s-t
Journal. February 11. 19861.
Ut -HcodIIIy" diet _y b.nde1>dukf, capen 1lIIY" lIu-o.tIII vlolle. JIlIy
12. 19116:9.
19. Gillick MR. Hcahh pmmooron .I<,"'"g. ;ond lhe 1"'.....1 <>flllr monallire.
J HeaIIb PoIil Policy Law 1984; 9:]69.117.
20. Y__ A, Leelley K. Sb.Wat eM. R.. - An .wop.. of aJII:lI'aia1
N EogI J Med 1983: 308:2515.
21. Koplaa JP, Sisco-ict DS, GoIdbawn OM. The ruts of exercise: a public
heahh MW of injuries IDd bawds. Public Hc:al1II Rep 1985; 100:189-95.
22 MedIanic D. ed. Handboo!< of be.tldI, bc:aIdI are. IDd IlIr bc:aIdI pafcs
siam. New yarlt: Free Press. 1983:591-601.
23.
J Pas Soc Psycbol1981; 41:397-406.
24. l'eoadIaker JW. The psycbology of pbysical sympcoms. New Yodt: lipiaa_
cr-verlat!. 1982.
25. Reiman AS. The _ aIII'lpIa. N EogI J Mcd 19110;

26. GoIemm D. FoqetfuI_ is ...... causiog man: worry Ibu it sbould. New
YoIt: T_. July I. 19S6:C1.
27. CIat M. Scan:iI ftJr. cun:. Nniswa:t. Allpsl 7,
28. WeiDer SL. Tampons IDd IDxic sbock syndrome; _ proa:aiaD ...
paIiIic c:cnfusiorrI? la: SapoIsky HM. ed. CoasumiDg fears: !be poIma. of
pmdacl risks. New YoIt:: Basic.&oats. 1986:14158.
29. Todd lIe TOXJC sIIock syudrome - sciaWic IIIICCIWDty and die paIiIic
__ P>:diaaic:s 1981; 67:921-3.
30. s-:tic 10, While GA. Plaia pic:Iun:s of plaiD doc:U!riag. 8os1oa: M.I. T.
Pna. 198.5.
31. BmtyAJ m. Hiddca tca$OIISsome YisiuloClIXS. AM Iab:m Med
1981; 904:492-8. '
32. a.m LR. DistlaI:Iiw c:UncII:ristics of ambuIaJry medicine. In: a.m
LR. BIIrDI .fit. Zievc PD. eels. PriDdpIc:s of ambuIIIIoIy 1DIIdic:iDe. BaJrj..
man:: WtItiIms &: wiIk.iD$. 1982:115.
33. Szasz T. idooIogy and iDsaIIity: essays ... die psyebiaric: debumanizarioD of
_. New YoIt:: Doubleday. 1910.
34. lUichl. Medic:alnemcsis: NewYodt: PandIeoa
Books. 1976.
35. Freidsoon E. Professioa of 1IICIIic:ine: a smdy of Ihe sodoIoiY of applied
New York: Dodd. Mad, 1970.
36. Coond P. ScImc:idcr JW. Deviance aM mc:dicaIizIIioa. 51. Louis: C. V
MosIIy. 1980.
37. Smilgis M. Snip. SIICIion. streu:b IDd INSS. T.-. SepIcmbcr 14. 1987:70.
38. Giddon DB. Tbrougb !be lcoiiDg gIus of pbysicims. demim, and plII'ioaIs.
1'enpa:t 8iol Med 1983; 26:451-8.
39. Fra:dman J. Happy pec!ple. New Yod:: Han:owt 8..- JovuoYidl, 1m.
40. Banlky AJ. Worried $id: our IIOIIbied quest for wellness. 8osIoII: UIIIe.
Broom (in presII).
Massachusefts Medical Society
Registry on Continuing Medical Education
r.. ohtain informal!"11 Oil "omiulliug medical edu(,ation cours('s ill !h.. Nt'w Enj(land .1.Cea.
writ, or ('all, indica,ial,( tic'Jdls) or spt"ciahv in which infrlrmation is dc.siITd.lht" Committe!" I
on Educall<ln. l-HlI \bin 51 .. Waltham. MA 022S4: 1..leph<lne (61iJ 893+61ll I
(Metr<ll".ii Ian Buston; nr \\' ATS 11l0l 1-322-230:1 1
437