On Iatrogenesis

Michelle Munyikwa // “Medicine changed me, but not in the ways I expected,” Rachel Pearson writes in her memoir of medical school, No Apparent Distress. The book is Pearson’s attempt to make sense of these changes, drawing the reader from her working class childhood to her unexpected presence in medical school and the events which transformed her into a physician. At the center of the work is Pearson’s repeated return to a fundamental truth of learning to heal: that part of the process entails a daily encounter with fallibility, of ourselves and the system in which we learn.

I read Pearson’s book on the bus to the clinic where I spent three weeks studying outpatient pediatrics. Every day I’d sit in the back corner, clutching this text, and connect my experience of medical education to her own. I sought comfort in her experience, and saw reflected in her transformation my own process of becoming a physician. The text was like a mirror for my own uncomfortable education, with all its highs and lows.

While Pearson does not frame her book this way, I came to see it as an exposition on iatrogenesis in all its forms. Iatrogenesis, from the Greek for “brought forth by the healer,” refers “to any effect on a person, resulting from any activity of one or more other persons acting as healthcare professionals or promoting products or services as beneficial to health, which does not support a goal of the person affected.” The term is most commonly used to refer to medical errors, or instances in which patients experience a negative outcome associated with care, like a surgical complication or an unintended side effect. But as social scientists have long acknowledged, iatrogenesis can take many forms. Most apparent in Pearson’s work is what might be called structural iatrogenesis, in which clinical harm is caused to patients by the bureaucracy of medicine which obstructs access to care.

Pearson’s work notes how medical students and other trainees come to be shaped, in turn, by witnessing this iatrogenesis. She is not alone in remarking upon this. For example, in a recent New York Times article, a medical student describes his discomfort upon realizing that his education would be dominated by practicing on those too poor or disenfranchised to refuse his inexpert exams. Mere feet away from one another, he practiced in two clinics: a well-resourced one, where his role was more circumscribed, and another, where he was encouraged to get involved. “It leaves a strange feeling in your gut, because it’s the most obvious example of how there’s different standards of care depending on your insurance status,” he said. “It’s like a tale of two clinics.”

It is this truth which Pearson illuminates so brilliantly. She often juxtaposes encounters in the student-run clinic with her other experiences in the hospital, illuminating structural abandonment. No Apparent Distress is also attentive to the precarious nature of charity care, demonstrated by the abandonment of indigent patients by UTMB after the devastation of Hurricane Ike. These passages brought me to my own experiences of working with — and learning on — poor people, folks of color, the uninsured, and the undocumented. Pearson describes the ambivalent position of the student clinic: part resource, and part educational setting. Her engagement with this knotty problem animates some of the most compelling scenes in the book. She wonders: is some care better than none? What does it mean when the safety net is staffed by people who are just beginning to understand how to provide care? In startlingly honest passages, Pearson reflects upon the consequences of these realities, cases of iatrogenesis which evidently haunt her to this day.

Pearson ends her reflection on her medical school experience on an ambivalent note, neither optimistic nor pessimistic. She contemplates a patient whose suffering was so great she couldn’t face him, missing her chance to say goodbye. She acknowledges that, in the face of agony, we are often tempted to look away, cloaking our feelings in cynicism or simply failing to show up. And yet, she writes: “I know now that returning to be with those who are suffering is no easy thing. I also know that it is my job.”

If iatrogenesis affects our patients, then it certainly shapes us as we are learning to care, for better or worse. Some research now suggests, for example, that encounters with structural iatrogenesis, among many other problems in contemporary American healthcare, negatively shape trainees and providers. It is increasingly suggested that the epidemic of physician burnout is, in fact, an epidemic of moral injury. When faced with the structural injustices of our system, it is common to experience cynicism, depression, and hopelessness.

No Apparent Distress reminds us that it is likely that we will err, and in our effort to heal, we will make missteps. Pearson also reminds us that we operate within a system designed to cause harm to patient and provider alike, a system which desperately needs fundamental rearrangement if it is ever to be just. In the meantime, work like Pearson’s is a salve, an assurance that, whatever else, I am not alone.

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