Iatrogenesis

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Ancient Greek painting in a vase, showing a physician (iatros) bleeding a patient

Iatrogenesis or iatrogenic effect (/ˌætrˈɛnɪk/; a Greek term, meaning "brought forth by the healer") is any consequence of medical treatment or advice to a patient.[1]

Some iatrogenic effects are clearly defined and easily recognized, such as a complication following a surgical procedure (e.g., lymphedema as a result of breast cancer surgery). Less obvious ones, such as complex drug interactions, may require significant investigation to identify.

Causes of iatrogenesis include:

Unlike an adverse event, an iatrogenic effect is not always harmful.[1] For example, a scar created by surgery is said to be iatrogenic even though it does not represent improper care and may not be troublesome.

Professionals who may cause harm to patients include physicians, pharmacists, nurses, dentists, psychologists, and therapists. Iatrogenesis can also result from complementary and alternative medicine treatments.

In the United States an estimated 225,000 deaths per year have iatrogenic causes, with only heart disease and cancer causing more deaths.[2][medical citation needed]

History[edit]

In his 1861 book, Semmelweis presented evidence to demonstrate that the advent of pathological anatomy in Vienna in 1823 (left vertical line) correlated with the incidence of fatal childbed fever there. Onset of chlorine handwash in 1847 marked by vertical line at far right. Rates for Dublin maternity hospital, which had no pathological anatomy, appear for comparison (view rates).

The term iatrogenesis means brought forth by a healer, from the Greek ἰατρός (iatros, "healer") and γένεσις (genesis, "origin"); as such, in its earlier forms, it could refer to good or bad effects.

Since at least the time of Hippocrates, people have recognized the potentially damaging effects of medical intervention. "First do no harm" (primum non nocere) is a primary Hippocratic mandate in modern medical ethics. Iatrogenic illness or death caused purposefully or by avoidable error or negligence on the healer's part became a punishable offense in many civilizations.[3]

The transfer of pathogens from the autopsy room to maternity patients, leading to shocking historical mortality rates of puerperal fever (A.K.A "childbed fever") at maternity institutions in the 19th century, was a major iatrogenic catastrophe of that time. The infection mechanism was first identified by Ignaz Semmelweis.[4]

With the development of scientific medicine in the 20th century, it could be expected that iatrogenic illness or death would be more easily avoided. Antiseptics, anesthesia, antibiotics, and better surgical techniques have been developed to decrease iatrogenic mortality.

Sources[edit]

Examples of iatrogenesis:

Causes and consequences[edit]

Medical error and negligence[edit]

Iatrogenic conditions do not necessarily result from medical errors, such as mistakes made in surgery, or the prescription or dispensing of the wrong therapy, such as a drug. In fact, intrinsic and sometimes adverse effects of a medical treatment are iatrogenic. For example, radiation therapy and chemotherapy — necessarily aggressive for therapeutic effect — frequently produce such iatrogenic effects as hair loss, anemia, vomiting, nausea, brain damage, lymphedema, infertility, etc. The loss of function resulting from the required removal of a diseased organ is iatrogenic, as in the case of diabetes consequential to the removal of all or part of the pancreas.

The incidence of iatrogenesis may be misleading in some cases. For example, ruptured aortic aneurysm is fatal in most cases; the survival rate for a ruptured aortic aneurysm is under 25%. Patients who die during or after an operation will still be considered as iatrogenic deaths, but the procedure itself remains a better bet than the 100% probability of death if left untreated.

Other situations may involve actual negligence or faulty procedures, such as when pharmacotherapists produce handwritten prescriptions for drugs.

Adverse effects[edit]

A very common iatrogenic effect is caused by drug interaction, i.e., when pharmacotherapists fail to check for all medications a patient is taking and prescribe new ones that interact agonistically or antagonistically (potentiate or attenuate the intended therapeutic effect). Such situations can cause significant morbidity and mortality. Adverse reactions, such as allergic reactions to drugs, even when unexpected by pharmacotherapists, are also classified as iatrogenic.

The evolution of antibiotic resistance in bacteria is iatrogenic as well.[5] Bacteria strains resistant to antibiotics have evolved in response to the overprescription of antibiotic drugs.[citation needed]

Certain drugs are toxic in their own right in therapeutic doses because of their mechanism of action. Alkylating antineoplastic agents, for example, cause DNA damage, which is more harmful to cancer cells than regular cells. However, alkylation causes severe side-effects and is actually carcinogenic in its own right, with potential to lead to the development of secondary tumors. In similar manner, arsenic-based medications like melarsoprol for trypanosomiasis can cause arsenic poisoning.

Adverse effects can appear mechanically. The design of some surgical instruments may be decades old, hence certain adverse effects (such as tissue trauma) may have never been properly cauterized. Some instruments that are long-standing parts of surgical kit would be unlikely to succeed if they were introduced anew; the collateral damage one "expects" to see with their use would be unacceptable if associated with a *new* product.

Psychology[edit]

In psychology, iatrogenesis can occur due to misdiagnosis (including diagnosis with a false condition as was the case of hystero-epilepsy[6]). An example of a partially iatrogenic condition due to common misdiagnosis is bipolar disorder, especially in pediatric patients.[7] Other conditions such as somatoform disorder and chronic fatigue syndrome are theorized to have significant sociocultural and iatrogenic components.[8] Posttraumatic stress disorder is hypothesized to be prone to iatrogenic complications based on treatment modality.[9] The psychological treatment of some conditions and populations, such as substance abuse[10] and antisocial youths[11] are regarded as carrying significant risks for iatrogenesis. At the other end of the spectrum, dissociative identity disorder is broadly considered to be a wholly iatrogenic disorder with the bulk of diagnoses arising from a tiny fraction of practitioners.[6][12]

The degree of association of any particular condition with iatrogenesis is unclear and in some cases controversial. The over-diagnosis of psychological conditions (with the assignment of mental illness terminology) may relate primarily to clinician dependence on subjective criteria.[citation needed] The assignment of pathological nomenclature is rarely a benign process and can easily rise to the level of emotional iatrogenesis, especially when no alternatives outside of the diagnostic naming process have been considered.[citation needed]

Iatrogenic poverty[edit]

Meessen et al. used the term "iatrogenic poverty" to describe impoverishment induced by medical care.[13] Impoverishment is described for households exposed to catastrophic health expenditure[14] or to hardship financing.[15] Every year, worldwide, over 100,000 households fall into poverty due to health care expenses. In the United States, medical debt is the leading cause of bankruptcy.[date missing][16] Especially in countries in economic transition, the willingness to pay for health care is increasing, and the supply side does not stay behind and develops very fast. But the regulatory and protective capacity in those countries is often lagging behind. Patients easily fall in a vicious cycle of illness, ineffective therapies, consumption of savings, indebtedness, sale of productive assets, and eventually poverty.

Social and cultural Iatrogenesis[edit]

The 20th century social critic Ivan Illich broadened the concept of medical iatrogenesis in his 1974 book Medical Nemesis: The Expropriation of Health[17] by defining it at three levels. First, clinical iatrogenesis is the injury done to patients by ineffective, unsafe, and erroneous treatments as described above. In this regard, he described the need for evidence-based medicine 20 years before the term was coined.[18] Second, at another level social iatrogenesis is the medicalization of life in which medical professionals, pharmaceutical companies, and medical device companies have a vested interest in sponsoring sickness by creating unrealistic health demands that require more treatments or to treat non-diseases that are part of the normal human experience, such as age-related declines. In this way, aspects of medical practice and medical-associated industries can produce social harm in which society members ultimately become less healthy, excessively dependent on institutional care. He argued that medical education of physicians contributes to medicalization of society because they are trained for diagnosing and treating illness therefore they focus on disease rather than on health. Iatrogenic poverty (above) can be considered a specific manefestation of social iatrogenesis. Third, cultural iatrogenesis refers to the destruction of traditional ways of dealing with, and making sense of, death, suffering, and sickness. In this way the medicalization of life leads to cultural harm as society members lose their autonomous coping skills. It is worth noting that in these critiques "Illich does not reject all benefits of modern society but rejects those that involve unwarranted dependency and exploitation."[19]

Incidence and importance[edit]

Iatrogenesis is a major phenomenon, and a severe risk to patients. In a study carried out in 1981 more than one-third of illnesses of patients in a university hospital were iatrogenic, nearly one in ten was considered major, and, in 2% of the patients, the iatrogenic disorder ended in death. Complications were most strongly associated with exposure to drugs and medications.[20] In another study, the main factors leading to problems were inadequate patient evaluation, lack of monitoring and follow-up, and failure to perform necessary tests.[citation needed]

In the United States, figures suggest estimated deaths per year of: [2][21] [22][23]

Based on these figures, iatrogenesis may cause 225,000 deaths per year in the United States (excluding recognizable error). An earlier Institute of Medicine report estimated 230,000 to 284,000 iatrogenic deaths annually.[2]

The large gap separating these estimates from annual deaths from cerebrovascular disease suggests that iatrogenic illness constitutes the third-leading cause of death in the United States; after heart disease and cancer.[2]

See also[edit]

References[edit]

  1. ^ a b Jacobs JP, Benavidez OJ, Bacha EA, Walters HL, Jacobs ML (December 2008). "The nomenclature of safety and quality of care for patients with congenital cardiac disease: a report of the Society of Thoracic Surgeons Congenital Database Taskforce Subcommittee on Patient Safety". Cardiol Young. 18 Suppl 2: 81–91. doi:10.1017/S1047951108003041. PMID 19063778. Retrieved 16 June 2014. 
  2. ^ a b c d Starfield B (July 2000). "Is US health really the best in the world?" (PDF). JAMA 284 (4): 483–5. doi:10.1001/jama.284.4.483. PMID 10904513. 
  3. ^ Wolf, Hanson, Moir, Friedman, Savage, ed. (July 12, 2011). Organization Development in Healthcare: Conversations on Research and Strategies. Advances in Health Care Management Series #10. Emerald Group Pub. p. 292. ISBN 978-0-85724-709-4. 
  4. ^ Hanninen, O; Farago, M.; Monos, E. (1983). "Ignaz Philipp Semmelweis, the prophet of bacteriology". Infection Control and Hospital Epidemiology 4 (5): 367–370. PMID 6354955. 
  5. ^ Finland M (1979). "Emergence of antibiotic resistance in hospitals, 1935-1975". Rev. Infect. Dis. 1 (1): 4–22. doi:10.1093/clinids/1.1.4. PMID 45521. 
  6. ^ a b Spanos, Nicholas P. (1996). Multiple Identities & False Memories: A Sociocognitive Perspective. American Psychological Association (APA). ISBN 1-55798-340-2. 
  7. ^ Pruett Jr, John R.; Luby, Joan L. (2004). "Recent Advances in Prepubertal Mood Disorders: Phenomenology and Treatment". Current Opinion in Psychiatry 17 (1): 31–36. doi:10.1097/00001504-200401000-00006. Retrieved 2008-05-04. 
  8. ^ Abbey, S.E. (1993). "Somatization, illness attribution and the sociocultural psychiatry of chronic fatigue syndrome". Ciba Found Symp 173: 238–52. PMID 8491101. 
  9. ^ Boscarino, JA (2004). "Evaluation of the Iatrogenic Effects of Studying Persons Recently Exposed to a Mass Urban Disaster". Archived from the original on 25 June 2008. Retrieved 2008-05-04. 
  10. ^ Moos, R.H. (2005). "Iatrogenic effects of psychosocial interventions for substance use disorders: prevalence , predictors, prevention". Addiction 100 (5): 595–604. doi:10.1111/j.1360-0443.2005.01073.x. PMID 15847616. 
  11. ^ Weiss, B.; Caron, A.; Ball, S.; Tapp, J.; Johnson, M.; Weisz, J.R. (2005). "Iatrogenic effects of group treatment for antisocial youths". Journal of Consulting and Clinical Psychology 73 (6): 1036–1044. doi:10.1037/0022-006X.73.6.1036. PMID 16392977. 
  12. ^ Braun, B.G. (1989). "Iatrophilia and Iatrophobia in the diagnosis and treatment of MPD (Morose Parasitic Dynamism)". Dissociation 2 (6): 43, 161–2, 165–6, 171–2 passim. PMID 9270707. Retrieved 2008-05-04. 
  13. ^ Meessen,B., Zhenzhong,Z., Van Damme,W., Devadasan,N., Criel,B., Bloom,G. (2003). "Iatrogenic poverty". Tropical Medicine & International Health 8 (7): 581–4. doi:10.1046/j.1365-3156.2003.01081.x. 
  14. ^ Xu et al.; Evans, DB; Carrin, G; Aguilar-Rivera, AM; Musgrove, P; Evans, T (2007). "Protecting Households from Catastrophic Health Spending". Health Affairs 26 (4): 972–83. doi:10.1377/hlthaff.26.4.972. PMID 17630440. 
  15. ^ Kruk et al.; Goldmann, E.; Galea, S. (2009). "Borrowing And Selling To Pay For Health Care In Low- And Middle-Income Countries". Health Affairs 28 (4): 10056–66. doi:10.1377/hlthaff.28.4.1056. PMID 19597204. 
  16. ^ "Medical Bills Leading Cause of Bankruptcy, Harvard Study Finds". 
  17. ^ Illich, Ivan (1974). Medical Nemesis: The Expropriation of Health. London: Calder & Boyars. ISBN 0-7145-1096-3. 
  18. ^ Pearce, Wright (2003). "Obituary: Ivan Illich". The Lancet 361 (9352): 185. doi:10.1016/S0140-6736(03)12233-7. 
  19. ^ Barnet, Robert (2003). "Ivan Illich and the Nemesis of Medicine". Medicine, Health Care and Philosophy 6 (3): 273–286. doi:10.1023/a:1025991708888. PMID 14620464. 
  20. ^ Steel K, Gertman PM, Crescenzi C, Anderson J (1981). "Iatrogenic illness on a general medical service at a university hospital". N. Engl. J. Med. 304 (11): 638–42. doi:10.1056/NEJM198103123041104. PMID 7453741. 
  21. ^ Leape L (May 1992). "Unnecessary Surgery". Annual Review of Public Health 13: 363–383. doi:10.1146/annurev.pu.13.050192.002051. 
  22. ^ Phillips DP, Christenfeld N, Glynn LM (February 1998). "Increase in US medication-error deaths between 1983 and 1993". Lancet 351 (9103): 643–4. doi:10.1016/S0140-6736(98)24009-8. PMID 9500322. 
  23. ^ Lazarou J, Pomeranz BH, Corey PN (April 1998). "Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies". JAMA 279 (15): 1200–5. doi:10.1001/jama.279.15.1200. PMID 9555760. 

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