Iatrogenesis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

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

The terms Iatrogenesis and Iatrogenic artifact refer to adverse effects or complications caused by or resulting from medical treatment or advice. In addition to harmful consequences of actions by physicians, iatrogenesis can also refer to actions by other healthcare professionals, such as psychologists, therapists, pharmacists, nurses, dentists, and others. Iatrogenisis is not restricted to conventional medicine and can also result from complementary and alternative medicine treatments.

Some iatrogenic artifacts are clearly defined and easily recognized, such as a complication following a surgical procedure. Some are less obvious and can require significant investigation to identify, such as complex drug interactions. And, some conditions have been described for which it is unknown, unproven or even controversial whether they iatrogenic or not; this has been encountered particularly with regard to various psychological and chronic pain conditions. Research in these areas is ongoing.

History

Etymologically, the term means "brought forth by a healer" (iatros means healer in Greek); as such, in its earlier forms, it could refer to good or bad effects.

Since Hippocrates's time, the potential damaging effect of a healer's actions has been recognized. The old mandate "first do no harm" (primum non nocere) is an important clause of medical ethics, and iatrogenic illness or death caused purposefully, or by avoidable error or negligence on the healer's part became a punishable offence in many civilizations.

With the development of scientific medicine in the 20th century, it could be expected that iatrogenic illness or death would be more easily avoided. With the discovery of antiseptics, anesthesia, antibiotics, and new and better surgical techniques, iatrogenic mortality decreased enormously.

Sources of iatrogenesis

Examples of iatrogenesis:

• medical error, poor prescription handwriting
• negligence or faulty procedures
• prescription drug interaction
• adverse effects of prescription drugs
• over-use of drugs leading to antibiotic resistance in bacteria
• nosocomial infection
• blood transfusion

Medical error and negligence

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 or chemotherapy, due to the needed aggressiveness of the therapeutic agents, frequent effects are hair loss, anemia, vomiting, nausea, brain damage etc. Excessive or inappropriate dependence on a therapist is a frequent example of iatrogenesis. The loss of functions resulting from the required removal of a diseased organ is also considered iatrogenesis, e.g., iatrogenic diabetes brought on by removal of all or part of the pancreas.

In other situations, actual negligence or faulty procedures are involved, such as when drug prescriptions are handwritten by the pharmacotherapist. It has been proved that poor handwriting can lead a pharmacist to dispense the wrong drug, worsening a patient's condition.

Adverse effects

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 which interact agonistically or antagonistically (potentiate or decrease the intended therapeutic effect). Significant morbidity and mortality is caused because of this. 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.Finland M (1979). "Emergence of antibiotic resistance in hospitals, 1935-1975". Rev. Infect. Dis. 1 (1): 4–22. PMID 45521. Bacteria strains resistant to antibiotics have evolved in response to the overprescription of antibiotic drugs.

Nosocomial infection

A related term is nosocomial, which refers to an iatrogenic illness due to or acquired during hospital care, such as an infection. Sometimes, hospital staff can be unwitting transmitters of nosocomial infections (in one of such instances, many hospitals have forbidden physicians to use long ties, because they transmitted bacteria from bed to bed when the doctor swept the tie over the patients when bending over them). The most common iatrogenic illness in this realm, however, are nosocomial infections caused by unclean or inadequately sterilized hypodermic needles, surgical instruments, and the use of ungloved hands to perform medical or dental procedures. For example, a number of hepatitis B and C infections caused by dentists and surgeons on their patients have been documented. One of the most horrid cases of massive death caused in recent times by iatrogenic infection has been reported on several bush hospitals in Zaire and Sudan, where the intensive reuse of poorly sterilized syringes and needles by nurses spread the Ebola virus, probably causing hundreds of deaths.

The use of contaminated vaccines was also an important source of iatrogenesis, because many of them are manufactured with live, but attenuated viruses or bacteria, and may become contaminated. Major occurrences were the many children who died of tuberculosis by the application of contaminated BCG vaccines, as well as the victims of some defective vaccine batches of polio vaccines by Dr. Jonathan Salk.

Psychology

In psychology, iatrogenesis can occur due to misdiagnosis (including diagnosis with a false condition as was the case of hystero-epilepsy). Conditions hypothesized to be partially or completely iatrogenic include bipolar disorder, dissociative identity disorder , fibromyalgia,somatoform disorder, chronic fatigue syndrome, posttraumatic stress disorder, substance abuse, antisocial youths and others though research is unequivocal for each condition. The degree of association of any particular condition with iatrogenesis is unclear and in some cases controversial.

Physician's wrongdoing

Although very rare, iatrogenic illness or death can be attributed to mental, nervous, sensorial or muscular disease in physicians. This may range from the banal, such as trembling fingers in a surgeon causing slippages and errors, or long medical resident work hours causing sleep deprivation-induced errors, to extreme cases such as the sociopathic physicians and nurses who kill scores of their patients (such as the Death Angels of Lainz, the British nurse Beverley Allitt and GP Harold Shipman), American physician Richard J. Schmidt (who tried to kill his girlfriend by contaminating her with AIDS-tainted blood), and the bizarre case of German surgeon Prof. Ernst Ferdinand Sauerbruch (1875-1951), who became demented and continued to perform absurd operations on many patients, with fatal results, even after his colleagues detected the errors but were unable to stop him because of his fame and power.

Medical torture can be regarded as an extreme form of iatrogenesis, i.e., the involvement and sometimes active participation of medical professionals in acts of torture, to either to judge what victims can endure, to apply treatments that will enhance torture, or as torturers in their own right. Unfortunately, many episodes of humankind's history, such as the Nazi use of torturous human experimentation by physicians such as Josef Mengele, have also witnessed extreme iatrogenesis. Although these could be considered rare instances in medical history, unethical medical experimentation is much more common, i.e., use of involuntary subjects or the inadequate handling of informed consent in clinical trials. Horrid perpetrations were recorded even in democratic countries, such as the famous episode of involuntary syphilis inoculation in African-Americans (Tuskegee Syphilis Study), or soldiers and sailors unwillingly subjected to radioactivity (Operation Plumbbob) in the USA.

Medical action, such as assisted suicide (by physicians such as Dr. Jack Kevorkian) and medical euthanasia are also forms of doctor originated (iatrogenic) death.

A related concept is Institutional Damage but it can occur separately from the medical acts, even in a hospital.

Cascade iatrogenesis

Cascade iatrogenesis is a series of increasingly more severe effects on the health of patients, caused by medical interventions which were applied to solve the previous one. A good example was a real case of a patient who had severe arthritis. Cortisone therapy at a high dose was instituted and was effective for a while, but prolonged use caused the first iatrogenic effect in the cascade: diabetes. Chronic diabetes increased the patient's susceptibility to infections and activated a latent pulmonary tuberculosis with hemoptysis. Cortisone treatment was suspended and substituted by ACTH therapy, which provoked adrenal insufficiency and severe osteoporosis, with painful spontaneous bone fractures (including fracture of ribs caused by an external cardiopulmonary resuscitation attempt. Generalized organ failure and infection followed, with death.

Incidence and importance

Iatrogenesis is a major phenomenon, and a severe risk to patients. A study carried out in 1981 more than one-third of illnesses of patients in a university hospital were iatrogenic, nearly one in ten were 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. 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.

In the United State alone, recorded deaths per year (2000):

• 12,000 -- unnecessary surgery
• 7,000 -- medication errors in hospitals
• 20,000 -- other errors in hospitals
• 80,000 -- infections in hospitals
• 106,000 -- non-error, negative effects of drugs

Based on these figures, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Also, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

This totals 225,000 deaths per year from iatrogenic causes. In interpreting these numbers, note the following:

• most data were derived from studies in hospitalized patients.
• the estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.
• the estimates of death due to error are lower than those in the IOM report. If higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

See also

• Adverse drug reaction
• Adverse effect (medicine)
• Bioethics
• Complication (medicine)
• Medical error
• Nocebo
• Patient safety
• Placebo
• Polypharmacy

Additional Resources

• Valenstein, Elliot S. (1986). Great and desperate cures: the rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books. ISBN 0465027105.

External links

• Patient Safety Network