An essay about iatrogenesis, yoga and antifragility.
Aunt Trudy was always different: she loved frogs and she loved to collect frogs – the artistic, porcelain kind. She had her prized porcelain frog proudly displayed in an open cabinet. Along side it was a cast iron frog given to her by her niece one Christmas, and, occasionally, a real live frog that her nephew would find for her. One day a slight earthquake shook the cabinet and they all fell off the shelf. The exquisite porcelain frog shattered upon impact with the floor; the iron frog merely bounced; while the real frog leapt to safety. The porcelain frog was fragile – any chaos was bound to harm it; the iron frog was robust – it didn’t matter what happened, it would always be unharmed, but not better than before; but the real frog was antifragile and actually benefited from the exercise of jumping. Sedentary life with no challenge or change was harmful to the real frog, but the stress of life made it stronger.
Human beings seem quite fragile: we break easily. But there are many respects in which we can be said to be antifragile. Antifragile is a word coined by the philosopher, writer and quant Nassim Nicholas Taleb: it refers to a condition where an entity gains from randomness, stress and disorder. We could use the example of our bones: compared to a beam of wood, which breaks down over time (the wood is fragile), our bones get stronger with repeated stress. They are antifragile: they gain strength, to a limit, with increasing stress. Something fragile suffers from chaos and change, as we saw in the above story of Aunt Trudy’s frogs. [See Figures 1-4 for graphic examples of the fragility-antifragility spectrum.] Machines, like a computer or a car, are fragile – they wear out over time, and with accumulating stresses. Living organisms, on the other hand, get stronger with time and stress. You are not a machine: stress (to a limit) makes you stronger, not weaker. You are antifragile in so many ways, as long as you continue to seek out an appropriate amount of stress in your life. Comfort is the opposite of stress: modern living tends to seek conditions where we have no stress, where we are comfortable, but this comes at a terrible cost: fragility.
|FIGURE 1 – Fragile: Here we see how stress beyond a certain tolerance level can cause a fragile object to be shattered or broken. The transition is sudden, once the tolerance level is reached.||FIGURE 2 – Robust: Here we see how, regardless of the stress levels, a robust object is unaffected by any amount of stress. Until a limit, it neither benefits from the stress, nor is it harmed.|
|FIGURE 3 – Antifragile: An antifragile object benefits from stress, up to a certain point. As stress increases, so too does the health and strength of an antifragile object. However, once a certain stress level is reached, the object is no longer antifragile, and it will suffer from continually increasing stress. At this point (B) the object is again fragile, but also notice, if stress stays at the level at point (A), the object will also be unhealthy.||FIGURE 4 – Fragility and Antifragility of Injured Tissues: When tissues are damaged, the tolerance at which they pass the threshold from antifragile to fragile moves to the left, to point C. Clearly, if stress is applied at the B level, the tissues will be damaged, but if the stress applied remains at point A, the tissues will remain fragile. Ideally the stress should be close to, but not beyond the edge represented by point C.|
Unfortunately, many yoga teachers in their well-meaning attempts to protect us and keep us from harm are actually making us more fragile, not less. The term for such unintended negative consequences from positively intended direction is iatrogenics. This term originated in the medical community: it literally means, “brought forth by a healer.” According to the Nutrition Institute of America, “the estimated total number of iatrogenic deaths-that is deaths induced inadvertently by a physician or surgeon or by medical treatment of diagnostic procedures-in the U.S. annually is 783,936.” That makes iatrogenesis as deadly as heart disease and cancer combined!
A New Scientist article cites many medical examples, but we need only look at one to make the point clear: “Take cancer. Anyone with experience of chemotherapy knows how dangerous its side effects can be: it can weaken a patient’s immune system to the point where they succumb to mundane infections. That is well understood, but recent discoveries about tumour cells’ ability to spread to other tissues suggest another – chemotherapy might sometimes make cancer more aggressive …” The intention of chemotherapy is to cure the cancer, but the unintended result may be to make cancer stronger, or weaken the body so much that other diseases arise. The challenge is – for some people, the chemotherapy is absolutely the right approach and can save their life, but for another person it is a death sentence, and we don’t know in advance how someone will react. This is the reality of human variations: we are not all the same. None of this is to deny modern medicine’s wonderful benefits: it has saved or prolonged millions of lives, but it also has a shadow side to it. The modern medical industry is sometimes lethal.
Nassim Nicholas Taleb, the writer who coined the term antifragile, described how iatrogenesis is also prevalent outside the medical realm. He points to many examples of well-intentioned interventions that have severe and negative consequences: we micromanage forests, putting out each and every small fire, but this creates conditions where a huge, devastating forest fire can, and will in time, occur; we prevent our children from getting dirty, washing them with antibiotic soaps, but this weakens their young immune system and makes them more susceptible to allergies and other autoimmune disorders as adults; we allow medium sized companies (i.e.; banks!) to acquire and merge with other companies to provide greater financial stability, but we create entities that are too large to fail, and when they inevitably do, they break the financial system. In the fitness industry, the term “no pain – no gain” is sometimes referred to as “Tough Love,” and while the intention is to make the participants healthier, iatrogenesis occurs at an alarming frequency. The list could go on and on, but – what does any of this have to do with yoga?
Do No Harm?
Every yoga teacher wants to do good for his or her students: like doctors we strive to “do no harm.” But, unfortunately, harm sometimes occurs. Teachers are no different in their intentions than nurses and doctors, but the prescriptions offered by teachers may be just as dangerous for the student as a well-intentioned prescription issued by a physician. Iatrogenics is not just mistakes by a doctor, it applies to situations where a doctor followed all the right protocols and procedures, the right medicine was issued, the patient took it in the right doses and times, but the patient died because of all these “right” processes, not in spite of these instructions.
This can and does happen in a yoga class as well. The teacher may follow all the instructions she learned in her teacher training course, she may have followed the latest discussions about whether to bend the knees or not while in a forward bend, whether to stress the spine or not if the student has osteoporosis, to find the right alignment for the neck in headstand, and the student may follow the instructions perfectly, and still an injury may result, not in spite of the right instructions being given and followed, but because they were given and followed.
Let’s examine just one illustrative example: a student comes to a yoga class for the first time, approaches the teacher and explains that she has osteoporosis in her lumbar spine. The teacher, well-trained and knowledgeable about osteoporosis, acknowledges the students conditions and offers directions and alternatives for her: she prohibits the student from any flexion at all in the spine, restricts twisting to the upper back only and then, only mildly, and also limits the amount of extension in backbends. The teacher rightfully believes that the student is close to the point labeled (B) in figure 3, but she prescribes for her student stress levels only at point (A), which is none at all. The teacher helps the student to minimize all stress to the lower back and checks constantly on the student to make sure that she is comfortable in every pose. Props are the student’s constant companions every time she comes to that class.
What is comfortable makes us fragile! The noble intention to do no harm to the student by making her comfortable, by minimizing or eliminating stress to the damaged areas causes those areas to become more and more fragile. Her lumbar joints atrophy further because of the reluctance of the teacher (and thus the student) to place any stress there. The student’s back becomes as fragile as a porcelain frog. The teacher’s intentions are commendable: her teaching harmful.
Risks & Rewards
William Broad’s articles and book, The Science of Yoga, caused controversy and debate in the yoga community when he listed many of the ways, through anecdotes, that yoga was causing harm to students. He was accused of shoddy reporting, selective sampling, and sensationalism. His stated aim was to make students aware of the “risks and rewards” of yoga. Broad was warning about the dangers of going too far, of employing too much stress, of going beyond point (B) of figure 3, and of iatrogenics – the harm caused by yoga even when it was properly taught. Again, this was not to imply that all yoga is harmful: it isn’t – yoga can be lifesaving and is very healthy and healing for most people, but not for everyone all the time. A reaction set in when the book was released which saw many yoga teachers go to the other extreme: if too much stress or challenge was bad, then it is better to have none at all. They went to point (A) on our curve. Dogmatic assertions switched from “always do this pose this way,” to “never do that pose that way.” But dogma is still dogma: Paul Grilley is fond of saying, “Never is never correct and always is always wrong.” As doctors have long known, we cannot have one prescription that will work for every patient. That is an important understanding, but it is one that is very hard to put into practice.
There are yoga teachers who insist that students must never do Pigeon Pose, or Headstand, or — pick an asana. There are teachers who claim that every time any student does a forward fold, whether standing or sitting, their knees must be bent. There are teachers, who, following their training, or their own experience, or even guided by valid logic, insist that students must always or never do such-and-such. Unfortunately, the reality is – by trying to do no harm, we may be preventing our students from getting the stress that they need to be healthy: we are making them fragile. Certainly, there are some students who really should not be stressing the challenged area. The problem is – how to know which student is which? Like the doctors who don’t know in advance which patient will be cured by chemotherapy and which patient will be killed by it, yoga teachers can’t know in advance what really is going to be best for our students.
It may seem quite counterintuitive to suggest that someone who has a fragile or damaged spine should deliberately stress it. The obvious course of action is to give it rest, but this debate has run its course in terms of women’s recovery after childbirth. At the turn of the 20th century the prevailing wisdom prescribed lots of bed rest to allow the new mother to recover her strength. In time it was realized that this was the worst thing to do for most mothers: they needed to become mobile as soon as possible. Indeed, a study published in Lancet suggests that bed rest is never a good idea for any conditions. By subjecting ourselves to small amounts of stress, we become antifragile. Figure 4 shows this graphically: if we extend Nassim Taleb’s logic to people who are injured, we find that they still need some stress or they will risk becoming more and more fragile.
Something that is harmful in excess, can build antifragility when given in small measure. King Mithridates VI of Pontus, who lived around 100 B.C.E., knew this. He was worried that his mother was going to poison him to death, as she did to his father. To protect himself, Mithridates started to ingest tiny amounts of various kinds of poisons every day, and over time increased the dosage. He became immune to poison.  This process has been called by pharmacologists hormesis – a small dose of something harmful can actually confer benefits. This is the principle behind many allergy cures and vaccinations: provide a small stress now so that the body can deal with larger stressors later on. With no stress, the king would have remained fragile with respect to poisons: with no stress, your spine will become fragile even to everyday movements.
In medicine, one way to reduce the occurrence of iatrogenesis is by leaving authority for all interventions in the patient’s hands. Informed consent means that the patient understands the situation she is facing, the options being offered, and all the possible consequences of those options, including any potential “side effects.”
For the record: drugs do not have side effects: they have direct effects. By calling some of these direct effects “side effects,” we are being subjected to a form of marketing that seeks to diminish the harm we may suffer. “Oh, it is only a side effect!” An unwanted effect of any medical intervention is not a side effect, it is a direct effect, and the patient needs to understand what these might be and how likely they are to occur in her situation. Without this knowledge, there is no informed consent.
One study looking into the question of how informed patient consent really is concluded, “Although physicians often describe the nature of decisions to their patients, they less often discuss risks and benefits and rarely assess patient understanding. Though invasive procedures require “informed consent,” it usually takes the form of seeking patient agreement with a recommendation, rather than quantifying the risks and benefits of alternative approaches. When well informed, patients often make different decisions from their physicians.” That’s the key: if you really knew what was going on, you might make a very different decision than your doctor.
We can seek the same understanding by our students in a yoga class. It is not possible or practical to give a student the same depth of knowledge and experience that a teacher has, but we can help to train students to look for warning signs that will let her know that she may be on the verge of harming herself. Teaching students what pain is, and how to respond to pain, is a start. Yoga is a practice that generates a wide variety of sensations, which only the student will experience. It is personal and it is subjective. The student has to learn to differentiate between “good” sensations, neutral ones and “bad” or harmful ones. But it is not enough to observe sensation only while in a class: the student should be alert for sensations that may arise in the next day or two as well, which may have been caused by her practice. She needs to develop awareness and sensitivity so she can correlate sensations with her current or prior actions.
Informed consent in a yoga practice means letting the student know what she can expect from the practice, the intention of a posture or movement, providing options in cases where things don’t follow the plan, and then giving over to the student the final decision to do the pose in the most effective way. This requires a functional approach to yoga, not an aesthetic approach. A dogmatic teacher that insists that there is only one way to do a forward fold may be helping most of her students stay healthy, but she may be making some student’s spines more fragile. This is not her decision to make! The student has to be the one to decide, but to make that decision, the student needs to know the options, and needs to be taught how to monitor her own response to postures.
Who is flying the plane?
So far, we have been talking about the yoga teacher: what if you are not a teacher, what if you are the student? How does any of this apply to you? The author and geneticist Bruce Lipton once asked an important question: “What’s the difference between a doctor and an airplane pilot?” Before delivering the punch line he pointed out that a pilot, by law, has to go through a large checklist of items before he can begin to taxi his plane away from the airport terminal. He always does this. Your doctor likewise is expected to go over a standard list of questions and procedures when you come to see her, but since she has only about 10 minutes allocated to your visit, she rarely does this. What’s the real difference between the doctor and the pilot? The pilot is on the plane with you. This bears repeating: The pilot is on the plane with you!
Lipton’s comment is not meant to disparage doctors, but none of them are on the plane with you. This also applies to dentists, accountants, lawyers, best friends, family and yoga teachers. You may be surrounded by bright, educated and well-intentioned people, but you are the one flying your plane. Experts can be part of your advisory team, a council of coaches, but you have to take final responsibility for your life, for your health, for your yoga practice.
Don’t take anything a yoga teacher tells you as gospel: check it out. The advice is well intentioned, but you are flying your plane. If the advice or directions do not work for you, don’t follow it. You are unique. Your teacher will never know you as well as you will know yourself. Her advice is guidance, but it is not a commandment from God. Beware of dogma no matter which expert is delivering it to you. How to know if the advice doesn’t work for you? Consider it, try it, but pay attention: pain is often a great signal that something isn’t right. If it is not right for you, ask for options.
You do not attend a yoga class for the teacher’s benefit: she is there for your benefit. If she is not benefitting you, find another teacher who will. You don’t have to be rude about this or ill-mannered, but neither do you have to do everything asked of you. Test it out, and if it doesn’t work, drop it. Theory is great, but never ignore your experience just because your experience is at odds with someone’s theory or philosophy.
The conclusion we can reach, considering the reality of iatrogenics, knowing that it occurs in yoga as well as in medicine, and considering that a lack of stress can make us fragile, is that we need stress. It has often been said, “No strain, no gain!” but keep in mind the Goldilocks Principle: too much strain is not good, but neither is too little. We need stress to build antifragility. Remember too – you are the one flying your airplane. Everybody else is on the ground. Listen to your ground control crew, but keep your hands on the stick.
- — See Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb, Random House, NY, 2012
- — “The frequency of stressors matters … Humans tend to do better with acute than with chronic stressors, particularly when the former are followed by ample time for recovery …” Ibid page 58
- — Iatromantis is Greek – its most literal meaning is simply “physician-seer,” or “medicine-man”; genesis means to create; so iatrogenesis refers to things caused by healers, however in this case we are referring to unintended, negative things.
- — See Death by Medicine by Gary Null et al in Life Extension Magazine, August 1, 2006, accessed August 6, 2014.
- — See Counting the hidden victims of medicine in New Scientist 24 January 2014, accessed August 6, 2014.
- — See Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb, Random House, NY, 2012
- — See PERSONAL FITNESS TRAINERS GIVING TOUGH LOVE: Risks and Consequences by Sekendiz, Betul M.Sc., Ph.D. in ACSM’S Health & Fitness Journal: May/June 2014 – Volume 18 – Issue 3 – p 8-11
- — “The comfortable is what fragilizes” – Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb, Random House, NY, 2012, page 339.
- — See The Science of Yoga by William Broad, Simon & Schuster, 2012, page 5.
- — His dictate also refers to his own statement! Take it with a grain or two of sea salt. “Never consume radioactive polonium” is always good advice.
- — This may be possible in the near future. Personalized medicine, based up genomic surveys, may tell us in advance which person will react negatively or positively to specific drugs or chemotherapy. It may be possible soon for doctors to create an intervention strategy tailored to each patient.
- — See Bed rest: a potentially harmful treatment needing more careful evaluation by Allen C, et al: Lancet 1999; 354:1229-33.
- — This may help explain how some yogis are reportedly able to ingest poisons without harm. It is said that these yogis have extremely strong agni, which is the fire of our digestion. This may be true, but it may also be due to hormesis.
- — Poor Mithridates: he was eventually conquered and captured by the Romans, and wanted to commit suicide to escape being humiliated in public, but he was unable to poison himself to death due to his prior practices.
- — See the editorial New decision making aids should help patients make the decisions by Richard A Deyo, professor of medicine, University of Washington, in BMJ 2001;323:466, Sept 1, 2001 accessed August 12, 2014
- — See the article Suzee Cues & Functional Yoga for a more complete explanation of the differences.
- — Please remember, this is not saying “No pain, no gain!” Strain – yes. Pain – not in a yoga class, thank you.
- — See the article The Goldilocks’ Position.