Iatrogenesis

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

Iatrogenesis (from the Greek for "brought forth by the healer") refers to any effect on a person, resulting from any activity of one or more persons acting as healthcare professionals or promoting products or services as beneficial to health, that does not support a goal of the person affected.

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.

While some have advocated using 'iatrogenesis' to refer to all 'events caused by the health care delivery team', whether 'positive or negative', consensus limits use of 'iatrogenesis' to adverse, or, most broadly, to unintended outcomes.

Causes of iatrogenesis include:

• side effects of possible drug interactions
• complications arising from a procedure or treatment
• medical error
• negligence
• unexamined instrument design
• anxiety or annoyance in the physician or treatment provider in relation to medical procedures or treatments
• unnecessary treatment for profit

Unlike an adverse event, an iatrogenic effect is not always harmful. 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.

Globally it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment up from 94,000 in 1990.

Sources

Examples of iatrogenesis:

• Risk associated with medical interventions
  • Adverse effects of prescription drugs
  • Over-use of drugs, (causing - for example - antibiotic resistance in bacteria)
  • Prescription drug interaction
• Medical error
• Wrong prescription, perhaps due to illegible handwriting, typos on computer.
• Negligence
• Nosocomial infections
• Faulty procedures, techniques, information, methods, or equipment.

Causes and consequences

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 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

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. Bacteria strains resistant to antibiotics have evolved in response to the overprescription of antibiotic drugs.

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.

Psychiatry

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

The degree of association of any particular condition with iatrogenesis is unclear and in some cases controversial. The over-diagnosis of psychiatric conditions (with the assignment of mental illness terminology) may relate primarily to clinician dependence on subjective criteria. 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.

Iatrogenic poverty

Meessen et al. used the term "iatrogenic poverty" to describe impoverishment induced by medical care. Impoverishment is described for households exposed to catastrophic health expenditure or to hardship financing. 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. 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

The 20th century social critic Ivan Illich broadened the concept of medical iatrogenesis in his 1974 book Medical Nemesis: The Expropriation of Health 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. 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."

Epidemiology

Globally it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment up from 94,000 in 1990.

In the United States estimated deaths per year include:

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

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.

History

Evidence demonstrating the advent of pathological anatomy in 1823 Vienna (left vertical line) correlated with incidence of fatal childbed fever. Onset of chlorine handwash in 1847 is noted (right vertical line). For comparison, rates for Dublin maternity hospital, which had no pathological anatomy. (view rates).(Semmelweis 1861).

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.

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.

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, better surgical techniques, evidence-based protocols and best practices continue to be developed to decrease iatrogenic side effects and mortality.

See also

• Adverse drug reaction
• Bedsore
• Bioethics
• Cascade effect
• Classification of Pharmaco-Therapeutic Referrals
• Fatal Care: Survive in the U.S. Health System (book)
• Journal of Negative Results in Biomedicine
• List of medicine contamination incidents
• Medical Malpractice
• Medicalization
• Nosocomial infection
• Nocebo
• Patient safety
• Placebo
• Risk-benefit analysis
• Polypharmacy
• Quaternary prevention
• Sentinel event

External links

• Patient Safety Network