Iatrogenesis

Iatrogenesis is the causation of a state of ill health or adverse effect or complication caused by or resulting from medical treatment. The word literally means "brought forth by a physician" (iatros means physician in Greek), though such conditions can also be the result of actions by other allied health sciences professionals, such as therapists, pharmacists, nurses, dentists. etc. From a sociological point of view there are three types of iatrogenesis, clinical iatrogenesis, social iatrogenesis, and cultural iatrogenesis.

History
Since Hippocrates's time, the potential nocive effect of a physician's actions has been recognized. The old mandate "do no harm" is an important clause of medical ethics, and iatrogenesis caused purposefully, or by avoidable error or negligence on the doctor's part became a punishable offence in many civilizations. Before medicine was a more exact and scientific subject, however, most medical actions were outright nocive to the patient, such as the widespread practices of bloodletting, purging, branding of wounds with fire, and many others. Well until the discovery of anesthesia and asepsis, going to hospitals was a truly dangerous thing, due to the trauma of surgery and the ever present risk of nosocomial infection.

Sources of iatrogenesis
There are many sources of iatrogenesis:
 * medical error
 * adverse effects
 * drug interaction
 * drug resistance
 * unproven or radical medical treatments
 * biased diagnosis
 * nosocomial infection
 * physician disabilities
 * sociopathic physicians
 * medical torture
 * unethical medical experimentation
 * assisted suicide
 * medical euthanasis
 * others

Iatrogenic conditions do not necessarily result from medical errors, such as mistakes made in surgery, or the prescription or dispensing of the wrong drug. In fact, intrinsic and sometimes adverse effects of a medical treatment are iatrogenic; for example, cancer therapy by 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, negligence or faulty procedures are involved, such as when drug prescriptions are handwritten by the doctor. 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 physicians 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 doctors, 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 and unproven medical treatments may also be considered a form of iatrogenesis with often deleterious results. This is the case of "cure or kill" or "desperate cure" approaches which were used in the past, such as psychosurgery (especially the lobotomy fad), some forms of shock therapy, and colostomy for treating recurrent infections. It is estimated that tens of thousands of individuals were unnecessarily operated upon, undergoing health risks, suffering other diseases and health problems, and even death, as a consequence.

Some have considered many of the more elaborate forms of mental illness to be iatrogenic, recently including dissociative identity disorder, formerly known as multiple personality disorder, and recovered memory syndrome. According to this belief, patients in therapy, who may initially have depression or post-traumatic stress disorder, respond to suggestion by the therapist by filling in the other expected symptoms of these disorders. This is why critics of dissociative identity disorder claim that the vast number of such case are found by just a few psychiatrists and psychologists.

A related term is nosocomial, which refers to an iatrogenic effect due to or acquired during hospital care, such as an infection. Sometimes, physicians, nurses and other people working in a hospital can be unwilling 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 effect 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, iatrogenesis 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 is 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 which 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 iatrogenesis by many.

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 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 a 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).