Iatrogenesis

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 be iatrogenic or not; this has been encountered particularly with regard to various psychological and chronic pain conditions. Research in these areas is ongoing.

Causes of iatrogenesis include medical error, negligence, and the adverse effects or interactions of prescription drugs. In the United States, 225,000 deaths per year may be iatrogenic, making it the third leading cause of death.^[1]

History

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

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 the time of Hippocrates, 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.

The transfer of pathogens from the autopsy room to maternity patients, leading to shocking historical mortality rates of puerperal fever at maternity institutions in the 1800s, 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. 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
• harmful emotional distress from the ascription of mental pathology nomenclature for transient personal problems

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. 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.^[2]

Psychology

In psychology, iatrogenesis can occur due to misdiagnosis (including diagnosis with a false condition as was the case of hystero-epilepsy^[3]). Conditions hypothesized to be partially or completely iatrogenic include bipolar disorder,^[4] dissociative identity disorder,^[5][3] fibromyalgia,^[6] somatoform disorder,^[7] chronic fatigue syndrome,^[7] posttraumatic stress disorder,^[8] substance abuse,^[9] antisocial youths^[10] and others^[11] though research is equivocal for each condition. The degree of association of any particular condition with iatrogenesis is unclear and in some cases controversial. The over-diagnosis of psychological conditions is not uncommon due to clinical dependence upon 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.

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.^[12] 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.^[13]

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.^[14]

See also

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

Footnotes

References

• 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