IATROSEDATION

Iatrosedation was defined in general terms as any technique of anxiety reduction in which no drug is given. At this point, a more specific definition of this same term is presented:

Iatrosedation: The relief of anxiety through the doctor’s behavior.

This definition of the term iatrosedation was formulated by Dr. Nathan Friedman, for many years the chairman of the Section of Human Behavior at the University of Southern California School of Dentistry. The word is derived from the Greek prefix iatro, meaning “pertaining to the doctor,” and the word sedation, meaning “the relief of anxiety.”⁸

The concept on which the technique of iatrosedation is based is rather simple: The behavior of the doctor and staff has a profound influence on the behavior of the patient. Other names have been applied to this concept, including “suggestion,” “chairside or bedside manner,” and “the laying on of hands.” The underlying premise of all these techniques is similar: One can use himself or herself to aid in relaxing the patient.

How important is iatrosedation in the overall concept of psychosedation? I have received extensive training in the administration of drugs for pharmacosedation and general anesthesia, yet I have received no formal training in any aspect of psychology or human behavior. It would appear therefore that I should have a strong bias toward the use of techniques requiring drug administration. When I first started my training in anesthesiology in 1969 this was true.

However, in the ensuing years, I have become acutely aware that iatrosedation is an integral part of the success (or possible failure) of every procedure that we in medicine and dentistry attempt. The success or failure of every pharmacosedative procedure also hinges on the use of iatrosedation.

Two classic studies illustrate the importance of human behavior in the control of pain and anxiety. In the first, Egbert et al⁹ demonstrated the value of the preoperative visit by the anesthesiologist to patients about to undergo surgery the next day. Patients were placed in one of three groups.

Group 1 received a preoperative visit from the anesthesiologist, but no preoperative drug for sedation before surgery. The purpose of the preoperative visit was to discuss the upcoming events with the patients and to answer any questions that they might pose to allay their fears. Group 2 received a sedative, pentobarbital, 1 hour preoperatively, but no preoperative visit from the anesthesiologist. Group 3 received both the visit from the anesthesiologist and the preoperative pentobarbital.

Results of the study demonstrated that patients in the first group were alert on arrival in the operating room, but were quite calm. They did not appear apprehensive. Patients in the second group were drowsy (the effect of the pentobarbital), but did not appear to be calm. They appeared quite concerned with the activities occurring around them. The third group, receiving both the visit and medication, were both drowsy and calm.

A second study by Egbert¹⁰ once again demonstrated the value of iatrosedative techniques in patients undergoing surgery. Patients scheduled for abdominal surgery were placed in one of two groups.

Patients in group 1 were not told about postoperative discomfort (pain) following abdominal surgery. Patients were told that analgesics would be available if they were required. Patients in group 2 (“special care patients”) were told that postoperative discomfort following abdominal surgery was quite usual and normal. The type of discomfort was described and its probable location. These patients were also told that analgesics would be available should they be required.

During the postoperative recovery period, patients in group 1 required twice the number of doses of analgesics for their discomfort as the patients who had been prepared for the discomfort. It appears that when pain is expected and is considered normal, the patient is better able to tolerate it. Put another way, it might be stated that pain that is expected by a patient simply does not hurt as much as unexpected pain. A significant anxiety component is noted with unexpected pain, a reaction that is not present with pain that is expected (normal). It is this anxiety (the fear that the presence of pain means that something is wrong) that makes the patient experience even more and greater discomfort. A second interesting finding in this study was that patients in the “special care” group recovered from their surgical procedure more rapidly and were discharged from the hospital an average of 2.7 days earlier than the patients in group 1. This may be because of the diminished requirement for analgesic drugs in the second group, leading to a reduction in drug-related side effects and complications that might impede recovery and discharge from the hospital.

These two studies by Egbert demonstrate the power of communication. I have been witness to many such demonstrations during the use of sedative drugs in dental practice. Unfortunately, not all communication works to the benefit of the doctor. This next case illustrates this point.

Communication is a powerful ally to the health professional. As these last cases illustrate, even when pharmacosedation is used, communication must never be ignored. Effective communication makes the drugs administered even more effective.

In the motion picture The Doctor,¹¹ a successful surgeon falls ill and enters into the contemporary health care system as a patient experiencing, as never before, the trials and tribulations that befall patients every day in the hospitals and medical centers of America. Through his negative experiences, the physician learns the value of communication and the importance of empathy in dealing with patients. This award-winning and highly successful film was based on a true story. Incoming residents in family practice medicine at the Long Beach (Calif.) Veterans Administration Hospital begin their hospital career as patients admitted to the hospital, undergoing the routines all patients face (hospital gowns, blood tests, impersonal attitudes by hospital staff).¹² Much of the commercial success of The Doctor was thought to be that audiences (all potential patients) believed that the message of the film struck home. The medical profession, to its credit, has recognized that the great emphasis placed in medical education upon the “scientific process” leads to the isolation of the physician from the patient and has begun to take steps to right the perceived wrongs. In a 1992 paper, Spiro¹³ states that “medical students lose some of their empathy as they learn science and detachment, and hospital residents lose the remainder in the weariness of overwork and in the isolation of the intensive care units that modern hospitals have become.” Medical schools have begun to modify their curricula, including in them new programs on communication and human behavior, designed to prevent the impersonalization of the physician.¹⁴

Similar programs have been in place for years in many dental schools throughout the United States and other countries. Yet in the highly competitive world that is dentistry today, it is often the patient who gets lost in the shuffle. I abhor the increasing use of the term client when discussing our patients. The importance of effective communication among the dentist and staff and patient can never be overemphasized. Interestingly, in the venue of continuing dental education, among the most popular programs offered are those in practice management—how to have a successful dental practice.¹⁵ The theme of communication is paramount in all these programs.