gerald_smallberg's picture
Practicing Neurologist, New York City; Playwright, Off-Off Broadway Productions, Charter Members; The Gold Ring
Iatrotropic Stimulus

This concept comes from epidemiology, the field of medicine comprising methods used to find the causes of health outcomes and diseases in populations. The meaning and relevance of this term require some historical background. 

When I was a medical student almost fifty years ago, I learned this concept from Dr. Alvan Feinstein, a professor of both medicine and epidemiology at Yale.  He taught a course in clinical diagnosis that would prepare us for seeing patients in the hospital. A strict and exacting teacher, he demanded that we learn to take a detailed and carefully crafted patient history, combined with a meticulous physical examination that were both crucial, he believed, to the art and science of medicine. Dr. Feinstein, as a cardiologist, had helped delineate the criteria that defined rheumatic heart disease. The critical role that rheumatic fever—caused by Streptoccocal infection—played in its pathogenesis could then be firmly established, so that early treatment of this infection became the standard of care to prevent this debilitating heart condition.

Feinstein's clinical research inspired his life-long study of the natural history of disease with the hope this would lead to better diagnosis and therapy. At the time he was my teacher, his research was focused on the epidemiology of lung cancer.  He was trying to analyze the optimal use of cancer screening studies, which was then and still is an issue that bedevils medicine.

Feinstein believed in making sure that the medical record contained the best data possible so that when it was reviewed retrospectively, unknown variables that were not appreciated when they were first obtained could be used to better classify patients into appropriate categories for ongoing and future clinical studies. He stressed to us that medical students had the best chance of recording this vital information in their case history as we were the most inclusive and least biased insofar as which data should be included. Every other patient note composed at each rung of the medical ladder, from the intern to the attending physician, was progressively streamlined and abbreviated to reflect the impression and conclusions that had already been formed. He read our reports fastidiously and underlined in red what he liked or didn't like, in the rigorous manner befitting his role as a teacher, journal editor, and clinical researcher. Along with the standard chief complaint, the patient's answer to the question, "What is bothering you, or why are you here?" he also wanted to know why the patient had decided to see a doctor at that particular time. It was the latter response that led Feinstein to coin the term iatrotropic stimulus, a phrase that combined the Greek iatros, or physician, with trope, “to turn.” In other words: What led the patient to seek help that day as opposed to another time when he may have been experiencing the same complaints? Perhaps the chronic cough that had been ignored was now associated with a fleck of blood or had become of greater concern because a friend or an acquaintance had just been diagnosed with cancer. In Feinstein’s view, this question would unleash information that could provide not only further epidemiological insights, but also would be invaluable in better understanding the fears, concerns, and motivation that drove the patient to seek medical care. Although well grounded in science and having studied mathematics before becoming a physician, he believed "clinical judgment depended not on a knowledge of causes, mechanisms, or names for diseases, but on a knowledge of patients." 

The iatrotropic stimulus never found its rightful place in the medical literature. After his course, I never used this term in any of my subsequent reports. Yet its clinical importance forever left its mark on me. It formed the back story, or mise-en-scène of my interaction, whenever possible, with my patients. As we get more and more data indelibly inscribed in an electronic record derived from encoded questionnaires, algorithm generated inputs and outputs that yield problem lists and diagnoses in our striving for more evidence based decision making, the human being can get lost in the fog of information.  In the end, however, it is the relationship of the patient and the treating physician that is still the most important. Together they must deal with complexity and uncertainty, the perfect Petrie dish for incubating fear and anxiety that, despite all technological progress, will remain the lot of the human condition. 

There are always problems to be addressed that are not limited to medical conditions but that happen to us as members of the larger society we inhabit. As we each try to confront these problems, the iatrotropic stimulus is an important concept to know—the "why now?" is a question for us to continually keep in mind.