One word that always made me feel the hairs stand on the back of my neck during university was iatrogenesis. If this word cropped up it would usually mean that a ‘fail’ would be appearing in my log-book very shortly after. Iatrogenesis stems from the Greek Iatros meaning ‘healer’ or ‘medical’ and genesis meaning ‘creation’. It is interesting to consider the proportion of the average general dentist’s workload that is correcting ‘healer’ created damage. For example, the damage a simple, inadequate contact point can do due to food-packing is considerable and tragic; often this occurs in patients with otherwise good oral health and hygiene. When one is confronted by lesions such as these, it is not hard to feel guilty. Somewhere over the hundreds and thousands of fillings placed in one’s professional life it is inevitable that each and every practitioner has their own stack of iatrogenic mishaps related to this issue of food-packing. But it isn’t just a problem with poor contacts, in every field there are bound to be some issues. Whether it is implants placed into ID canals or perforations in endodontics, no-one is left out; everyone gets to be part of this club. One would hope that we all do far more good for our patients than the harm that iatrogenesis might cause. If these iatrogenic mishaps are managed well, unpleasant fallout can usually be avoided. Even in these most litigious of times, most patients are not looking to turn to the courts in the first instance, so there is usually much scope in which to mend bridges (if you will pardon the pun).
I imagine I would have very little dissent in stating that the avoidance of clinical iatrogenesis is important. The theologian, philosopher and critic of medicine Ivan Illich shared this view, but expanded iatrogenesis into three parts. The clinical aspect discussed above is the first part. It is the obvious part for us dentists, the part drummed into us as dental students. For those who took the Hippocratic Oath (or equivalent) on qualifying, it is the antithesis of ‘First do no harm’. The other parts are social iatrogenesis and cultural iatrogenesis which are often lesser considered but in my view just as important.
One of the bugbears we dentists have (as well as other healthcare professionals) is the feeling that patients often want to delegate responsibility for their health to us. It’s annoying isn’t it? We’ve all been there when patients turn round and act as if their health issues are our fault. Have you ever considered that they might be? The idea behind social iatrogenesis is that medicine (and its allies) has over-medicalised society and disease, meaning that medicine behaves as if it has the answers to all. We as dentists classify and categorise our patient’s oral health complaints with names they can’t remember or pronounce. Is it any wonder they then hold us responsible for their problem, if we understand it and they don’t, surely that is the logical conclusion? “You know best” is a phrase I am sick of hearing from patients, because often I don’t. Perhaps if it was my mouth or body that decisions were being made over I could actually claim to know best, but it isn’t. The professionals of yore spent so long building up the profession to be a closed society, with our own language, abbreviations and tools of the trade that the public has an impression of us in their mind of being unapproachable that is hard to shift. The lawyers have enjoyed feasting upon this mistake with our poor and understandably confused patients left stood in the middle. All this is from our own creation, so I feel that Illich certainly has a point classifying this social effect as iatrogenesis.
Cultural iatrogenesis is perhaps even more scathing of the sociological effect we have upon our society. Illich states that medicine has prevented patients from being able to deal with their own realities. By this he means that by making it culturally desirable to have, for example straight teeth, it becomes impossible for those without this characteristic to accept their phenotypical situation. By medicalising every aspect of our health, we suddenly make anything that deviates away from that which is considered to be ‘perfect’ culturally unacceptable. Before the advent of whitening and porcelain veneers, patients accepted their natural tooth colour- I heavily doubt many people lay in bed at night worrying over these issues before there was an option to change them. There are of course those devastating conditions which do need our attention, but these are in the minority. I was always taught that malocclusion was not a disease, but dentists seem to have made it unacceptable for those without straight teeth to be happy with their oral situation. I want to avoid the quagmire of justifying orthodontic treatment on the NHS, as a beneficiary myself it seems rather hypocritical to comment; but is it right to create this demand for perfection and take away our patients’ abilities to cope with their realities? NHS patients sometimes expect cosmetic treatment to be funded by the state because we make it out to be so important. In doing so, we perpetuate the belief that one needs a beautiful smile. Surely it reflects poorly upon us when our treatments can serve to further the inequalities within society and make patients, who would have previously been content, reliant upon us for their happiness.
Iatrogenesis is the inevitable ying to the yang of providing care. We all should have an appreciation of the fact that whilst we can do great good with our skills, we can also do great harm. It is that harm that we have to accept, take responsibility for and fix. The responsibility for not over-selling and creating over-expectation is ours and ours alone, a responsibility that is becoming all the more important for us to embrace. A gentle flick through this magazine will reveal the extent to which complex restorative and surgical techniques can be used to our patients benefits. When I graduated from dental school, the majority of my year aspired to providing implants, non-surgical facial aesthetic treatments and the cosmetic finery made available by the advent of the CAD-CAM machine. Whilst these are truly exciting times for the prospective cosmetic dentist, we must remember that the disease processes that are our bread and butter, and also essentially our purpose for being as a profession, are still in need of our attention. One of the criticisms of modern medicine and dentistry is that we are still so superior in our views of the treatment we provide, it is not possible for those who are not dentists and doctors to relate to our aspirations and aims for the very treatments we aim to help them with. We still have our own language, obscure tools and we still often struggle to explain treatments and concepts in lay-terms. This is the trouble with modern healthcare, that unlike those surgeons of old; this is not actually acceptable. In an age where seemingly beneficial public health measures (such as water fluoridation and smoking restrictions) are heavily criticised by public opinion due to not respecting individual autonomy enough, it is not acceptable as a profession to be paternalistic in this manner.
It might be relatively easy to avoid damaging the teeth next to our fillings, but we have a bigger challenge ahead of us to avoid creating a shroud of mystery about our practises that prevent patients engaging with improving their oral health. We need to control the expectation that we create, not only from an iatrogenic point of view, but also from the point of a patient satisfaction angle where we don’t want to lead patients to being disappointed and looking for redress. In an age with the internet, the rise of the complimentary professions and a change in public perception of what we do; we need to earn our right to remain as the leaders of the dental team, certainly doing more good than harm is a positive step towards this.