Iatrogenesis



Iatrogenesis, or an iatrogenic artifact (, 'originating from a physician') is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, and dentists. Iatrogenesis is not restricted to conventional medicine: It 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 less obvious ones can require significant investigation to identify, such as complex drug interactions. Furthermore, some conditions have been described for which it is unknown, unproven, or even controversial whether they are iatrogenic or not; this has been encountered in particular with regard to various psychological and chronic-pain conditions. Research in these areas continues.

Causes of iatrogenesis include chance, medical error, negligence, social control, unexamined instrument design, anxiety or annoyance related to medical procedures, and the adverse effects or interactions of medications. In the United States, an estimated 44,000 to 98,000 deaths per year may be attributed in some part to iatrogenesis. .

History


The term iatrogenesis means brought forth by a healer (from the Greek iatros, healer); 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 potential damaging effects of a healer's actions. 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 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, and better surgical techniques have been developed to decrease iatrogenic mortality.

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, due to the needed aggressiveness of the therapeutic agents, frequently produce iatrogenic effects such as hair loss, anemia, vomiting, nausea, brain damage, lymphedema, infertility, etc. The loss of functions resulting from the required removal of a diseased organ also counts as iatrogenesis, thus we find, for example, iatrogenic diabetes brought on by removal of all or part of the pancreas.

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 decrease 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 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 characterized. Some instruments that are long-standing parts of surgical kit would be unlikely to succeed if they were introduced anew; the collateral damage one "expects" to see with their use would be unacceptable if associated with a *new* product.

Psychology
In psychology, iatrogenesis can occur due to misdiagnosis (including diagnosis with a false condition as was the case of hystero-epilepsy ). Conditions hypothesized as 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 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 (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.

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 was 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 States, figures suggest estimated deaths per year of:
 * 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).

These estimates are lower than those in an earlier IOM report, which would suggest from 230,000 to 284,000 iatrogenic deaths.

These figures are likely exaggerated, however, as they are based on recorded deaths in hospitals rather than in the general population. Even so, the large gap separating these estimates, deaths from cerebrovascular disease would still suggest that iatrogenic illness constitutes the third-leading cause of death in the United States; heart disease and cancer are the first- and second-leading causes of death, respectively.