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Related Topics:Iatrogenesis
Iatrogenesis literally means "brought forth by a healer" (iatros means healer in Greek); as such, it can refer to good or bad effects, but it is almost exclusively used to refer to the causation of a state of ill health or adverse effect or complication caused by or resulting from medical treatment. From a sociological point of view there are three types of iatrogenesis, clinical iatrogenesis, social iatrogenesis, and cultural iatrogenesis. While iatrogenesis is most often used to refer to the harmful consequences of actions by physicians, it can equally be the result of actions by other medical professionals, such as psychologists, therapists, pharmacists, nurses, dentists. etc. Further, iatrogenic illness or death is not restricted to Western medicine: alternative medicine (sometimes referred to as complementary medicine) may be considered an equal source of iatrogenesis for the same reasons.
History
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
There are many sources of iatrogenesis:
- physician error
- prescription drug interaction
- adverse effects of prescription drugs
- unproven or radical treatments
- biased diagnosis
- nosocomial infection
- medical torture
- unethical medical experimentation
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, etc.
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.
A very common iatrogenic effect is caused by drug interaction, i.e., when pharmacotherapists fail to check for all medicaments 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 sometimes is called iatrogenic as well. Bacteria strains resistant to antibiotics have evolved in response to what some call the overprescription of antibiotic drugs. In some parts of the world, antibiotics are prescribed much more frequently than in others, partly because people have come to expect them to be effective and thus to demand them from doctors. The habit of some patients to discontinue an antibiotic regimen as soon as their symptoms abate -- rather than taking the full course to ensure the bacteria are wiped out -- can also accelerate bacterial evolution towards resistance.
Radical or unproven medical treatments may also be considered a source of iatrogenic illness or death. This is the case of "cure or kill" or "desperate cure" approaches which were used in the past, such as psychosurgery (such as lobotomy), some forms of shock therapy, and colostomy for treating recurrent infections.
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 reclining upon 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.
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), 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 negros (Tuskegee Syphilis Study), or soldiers and sailors unwillingly subjected to radioactivity (Operation Plumbbob) in the USA.
Controversial aspects of medical action, such as assisted suicide (by physicians such as Dr. Jack Kevorkian) and medical euthanasia are considered iatrogenic death by some.
A related concept is Institutional Damage but it can occur separately from the medical acts, even in a hospital.
Incidence and importance
Iatrogenesis is a major phenomenon, and a severe risk to patients. A study carried out in 1981 "found that 36% of 815 consecutive patients on a general medical service of a university hospital had an iatrogenic illness. In 9% of all persons admitted, the incident was considered major in that it threatened life or produced considerable disability. In 2% of the 815 patients, the iatrogenic illness was believed to contribute to the death of the patient. Exposure to drugs was a particularly important factor in determining which patients had complications." (Steel et al., 1981). In another study, done in 101 adverse iatrogenic events in 84 patients, "the most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform a test (12.7%)." (Weingart et al., 2000).
See also
- Adverse drug reaction
- Adverse effect (medicine)
- Bioethics
- Complication (medicine)
- Dr. Death
- Iatrogenic disorder
- Medical error
- Nocebo response
- Patient safety
- Placebo (origins of technical term)
- Polypharmacy
Bibliography
- Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638-642. PMID 7453741
- Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470-477. PMID 10940133
- Valenstein, Eliott: Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness.
- Youngson, R.M.. The demented surgeon is operating. In: Medical Curiosities. Carroll & Graf, New York, 1997.
External links
"Iatrogenesis"