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Iatrogenesis & the iatrogenic potential of words.

Updated: Jan 7

Definition:

THE CAUSATION OF A DISEASE, HARMFUL COMPLICATION, OR OTHER ILL EFFECT BY ANY MEDICAL ACTIVITY, INCLUDING DIAGNOSIS, INTERVENTION, ERROR, OR NEGLIGENCE.


Quotes from this post are taken from:

BARSKY, A., 201 7 . THE IATROGENIC POTENTIAL OF THE PHYSICIAN’S WORDS. JAMA, 318(24), P.2425.


WORDS CAN HAVE AN IATROGENIC EFFECT

'Some of the information that physicians convey to their patients can inadvertently amplify patients symptoms and become a source of heightened somatic distress. One mediator of this variability between symptoms and disease is the patient’s thoughts, beliefs, and ideas.'

WHEN WORKING WITH PEOPLE WE SHOULD TAKE CARE WITH LANGUAGE


'These cognitions can amplify symptoms and bodily distress. Although cognitions may not cause symptoms, they can amplify, perpetuate, and exacerbate them, making symptoms more salient, noxious, intrusive, and bothersome.
Knowledge of the nonspecific...adverse effects of a drug (such as fatigue, difficulty concentrating, nausea, dizziness, headache) increases the frequency with which they are experienced and reported.'

FAILURE TO DO SO COULD CAUSE UNINTENDED NOCEBO EFFECTS

'For example, in a study of 76 patients who received β-blocker treatment for hypertension, erectile dysfunction occurred in 32% of the 38 patients explicitly informed of this adverse effect and in 13% of the 38 patients not specifically warned about it.
Likewise, in a double-blind trial of statins, the incidence of muscle-related adverse effects increased from 1.00% per year to 1.26% per year when patients (n = 9899) were subsequently unblinded and given the active drug.

MORE TESTS AREN'T ALWAYS HELPFUL

'Providing test results of dubious clinical significance also can lead to increased symptoms. For example, in a randomised study of acute low back pain, one group (n = 210) underwent spine imaging, whereas the other group (n = 211) did not. A treatment plan of conservative medical management was implemented in both groups. At 3- month follow-up, the former group had significantly more pain, greater functional impairment, and more physician visits.'

(The findings of these imaging results are referred to by the author as 'incidentalomas' or anatomical abnormalities of unknown clinical significance.)


PAIN IS SENSITIVE TO BELIEFS, THOUGHTS, AND EXPECTATIONS


The specific language used in describing and preparing patients for painful procedures can affect the pain experience.


In a randomised study of women receiving epidural anesthesia or spinal anesthesia (n = 140) for childbirth, those told that the intradermal injection of a local anesthetic would “feel like a bee sting: this is the worst part of the procedure” reported significantly more pain than did those told “the local anaesthetic will numb the area and you will be comfortable during the procedure.'

MORE INFO CAN INITIATE A SELF PERPETUATING AND VALIDATING CYCLE OF SYMPTOM AMPLIFICATION.


'Learning that a symptom may be more medically significant amplifies it. Reattributing the symptom to a new and more concerning source then causes the patient to monitor and scrutinise the symptom more closely, and this heightened attentional focus amplifies the symptom, making it more intense.
The misattribution also launches a selective search for additional symptoms to corroborate the suspicion that something is wrong, resulting in a heightened awareness of other transient symptoms that were previously ignored'


MODULATING SYMPTOM AMPLIFICATION AND MINIMISING UNDUE DISTRESS IN COACHING


Building upon the the review, these suggestions are my take on how we might aim to minimise iatrogenic harms or nocebo effects in the fields of coaching.


  • Exploring the person's ideas and beliefs about how an intervention may work.

E.g. 'What do you know already of how weight change happens?'


  • Education on the process of symptom/ pain/ experience amplification. Education is tailored to the person's current level of understanding.


  • Care with language. Emphasising why the intervention helps and examples of similar people that it has helped. E.g.

'This exercise improves blood flow to the knee joint and surrounding tissues, taking nutrients there. My client Jennifer who you saw yesterday has been doing this movement too and reported that her knees have been feeling less painful in the morning.'


  • Using neutral language to describe experiences rather than focusing on potential negative effects or using hyperbolic language.

E.g. 'Some soreness would be normal following this training' vs. 'If you feel sore tomorrow let me know ASAP so we can avoid that kind of damage again.'


  • Providing the person with choices or control over how the intervention will work.

'Which option sounds good to you?'


  • Tests that offer insignificant findings, that do not alter management, should be avoided without good reasoning.

For example, bloodwork to seek out poorly defined nutritional insufficiencies or food intolerances, exercise tests such as the FMS to identify 'dysfunctions' or limitations, routine 1RM tests in non competitive lifters, encouragement to seek out diagnostic imagery for minor aches and pains that do not warrant referral to a GP.



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Check out that review piece:

BARSKY, A., 201 7 . THE IATROGENIC POTENTIAL OF THE PHYSICIAN’S WORDS. JAMA, 318(24), P.2425.