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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 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 a source of iatrogenesis for the same reasons.

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1 History
2 Sources of iatrogenesis
3 Cascade iatrogenesis
4 Incidence and importance
5 Bibliography
6 See also

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:

medical error
negligence or faulty procedures
Doctor assisted suicide (e.g. Euthanasia )
poor prescription handwriting
prescription drug interaction
adverse effects of prescription drugs
underestimating potentially negative drug effects
over-use of drugs leading to antibiotic resistance in bacteria
radical treatments
misdiagnosis
nosocomial infection
mental, nervous, sensorial or muscular disease in physicians (very rare)
medical torture
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, 1979). Bacteria strains resistant to antibiotics have evolved in response to the overprescription of antibiotic drugs.

Unproven medical procedures

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. Other related cases where adhesion to crackpot medical theories have provoked undue harm to patients by physicians. Examples abound:

Wilhelm Fliess, an Austrian otolaryngologist proposed the existence of a nasal reflex neurosis, treating many patients through anaesthetization of the nasal mucosa with cocaine, and through nasal surgery. His noted friend Sigmund Freud believed him and referred several patients for this kind of treatment;
Sir William Arbuthnot Lane, a British surgeon who performed hundreds of radical colectomies (total surgical extirpation of the colon) because he believed that poisoned colons were a source of several diseases such as constipation, self-intoxication and the like;
The entirely unwarranted surgical removal of the palatine uvula was performed for several decades for a number of ills and for the supposed prevention of throat infections.

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 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 [1].

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 childred who died of tuberculosis by the application of contaminated BCG vaccines, as well as the victims of some defectiva vaccine batches of polio vaccines by Dr. Jonathan Salk.

Iatrogenic artifact

An iatrogenic artifact is a disease made up by doctors, often a diagnostic trend or fad that has become or is expected to become obsolete or discredited. Examples of diseases considered or accused of being iatrogenic artifacts include nymphomania, hystero-epilepsy, repressed memory, autogynephilia, and multiple personality disorder. In many cases, it has been shown that "experts" who believe in the disease are able to observe or even induce symptoms matching the disease's description in suggestible patients. Behavioral disorders are particularly susceptible to artifacts. For example, in the false memories syndrome: thousands of psychotherapists have attempted to recover memories of early childhood abuse from their clients. The techniques, practices and exercises used in these attempts are often referred to as Recovered Memory Therapy and sometimes resulted in allegations of abuse being made by individuals against family members. Many of these individuals severed all connection with their parents, hundreds of whom were convicted of these "crimes" and imprisoned.

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 (for an account, see Youngson, 1997).

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^{[citation needed]} 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 "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).

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.

(Dr. Barbara Starfield of Johns Hopkins School of Hygiene and Public Health, Journal of the American Medical Association, July 2000)

Bibliography

Finland M. Emergence of antibiotic resistance in hospitals. Rev Infect Dis 1979; 1:4-21. PMID 45521
Fisher-Hoch SP. Lessons from nosocomial viral haemorrhagic fever outbreaks. Br Med Bull. 2005 Dec 22;73-74:123-37. PMID 16373655
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
Valenstein, Eliott: Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness.
Vance MA, Millington, WR. Principles of Irrational Drug Therapy. British Naturopathic Journal 1990; 13(3). Full paper
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
Youngson, R.M.. The demented surgeon is operating. In: Medical Curiosities. Carroll & Graf, New York, 1997.