Iatrogenicity

Ihor Gussak, John Kostis, Ibrahim Akin, Martin Borggrefe, Giovanni Campanile, Arshad Jahangir, Willam J Kostis, Gan-Xin Yan

• Publisher: Rutgers University Press Medicine
• Year: 2017
• ISBN:
  9780813586427
• Topic: Medicine
• Subtopic: Cardiology

Iatrogenesis is the occurrence of untoward effects resulting from actions of health care providers, including medical errors, medical malpractice, practicing beyond one’s expertise, adverse effects of medication, unnecessary treatment, inappropriate screenings, and surgical errors. This is a huge public health issue: tens to hundreds of thousands of deaths are attributed to iatrogenic causes each year in the US, and vulnerable populations such as the elderly and minorities are particularly susceptible.  Edited by two renowned cardiology experts, Iatrogenicity: Causes and Consequences of  Iatrogenesis in Cardiovascular Medicine addresses both the iatrogenicity that arises with cardiovascular interventions, as well as non-cardiovascular interventions that result in adverse consequences on the cardiovascular system. The book aims to achieve three things: to summarize the available information on this topic in a single high-yield volume; to highlight the human and financial cost of iatrogenesis; and to describe and propose potential interventions to ameliorate the effects of iatrogenesis. This accessible book is a practical reference for any practicing physician who sees patients with cardiovascular issues..
 

PART I

Medical Harm

IHOR B. GUSSAK
WILLIAM J. KOSTIS

CHAPTER 1

Iatrogenicity

Definition, History, and Modern Context

MARIA L. GUSSAK, IHOR B. GUSSAK, AND JOHN B. KOSTIS

… ωϕελεειν η μη βλαπτειν … (… to help, or at least to do no harm …)

HIPPOCRATES, EPIDEMICS, BK. I, SECT. XI, C. 400 B.C.

INTRODUCTION

This book requires a caveat, one that all of its authors kept in mind while writing: the discussion of iatrogenicity is not motivated by emotional appeals, although we recognize with deep sadness that countless patients, family, friends, and medical personnel have been touched by iatrogenic complications or medical harm. This book is intended to lay a foundation for establishing iatrogenicity as a new clinical discipline. It is meant to serve as a reference for caregivers in better understanding the preventable nature of iatrogenic harm and learning from their own and others’ mistakes and misconceptions without accusing or blaming anyone. Rather, maintaining a scientific approach to and perspective on medical harm, whether intended or unintended, is crucial to furthering medicine. Moreover, we are cautious about calling iatrogenicity a “problem.” The important message is that facts and statistics matter; this book was not written to point fingers or expose ill practices.

We aim to prove that iatrogenicity has always been a part of medicine since its beginning and will continue to be for as long as medicine exists as an art and a science.

We hope that this chapter finds you well, causes you to raise questions, and increases your awareness for doing what is right not only for your patient but also for yourself, the clinician, student, nurse, or caregiver for whom we wrote this book.

Defining Iatrogenicity

It is important to review the definitions of health, medicine, medical harm, and adverse event.

The word health comes from the word for whole. To heal means to restore to a state of wholeness, soundness, or integrity.

“… Health is completeness and perfection of organization, fitness of life, freedom of action, harmony of functions, vigor and freedom from all pain and corruption—in a phrase, it is ‘a sound mind in a sound body’ ” (1).

“Not only is health a normal condition, but it is a duty not only to attain it but to maintain it” (2).

Taber’s Cyclopedic Medical Dictionary defines medicine as (a) a drug or remedy and (b) the act of maintenance of health, and prevention and treatment of disease and illness. Note the emphasis on a health- and prevention-based system. Medical harm is defined as an outcome that negatively affects a patient’s health and/or quality of life, whereas adverse event is an event that results in unintended harm to the patient. Both are iatrogenic, that is, related to the care and services provided to the patient rather than to the patient’s underlying medical conditions. Iatrogenic disease may result from medical error, malpractice, out-of-scope practices, adverse events, harm that exceeded benefit of a drug or procedure, unnecessary treatments, unnecessary screening, improper training, and miscommunications.

Taber’s defines iatrogenesis (the term from which iatrogenicity is derived) as follows:

Iatrogenesis [from Greek: iatros, physician + gennan, to produce] is any injury or illness that occurs as a result of medical care, for example, (a) chemotherapy used to treat cancer may cause nausea, vomiting, hair loss, or depressed white blood cell counts, or (b) the use of a Foley catheter for incontinence can create a urinary tract infection and urinary sepsis.

Of note is that this definition is followed immediately by these words: “A guiding principle of health care is to do little to patients while effecting cures—but this ideal is not always achieved. In the U.S., deaths that result from healthcare errors and complications of treatment are among the most common causes of mortality” (3).

Iatrogenicity has existed as long as medicine itself. In Epidemics Bk. I, Sect. XI, the followers of Hippocrates acknowledged the possibility of harmful effects of medical interventions in the statement, “With respect to the diseases, [the physician] should strive for two things: to benefit or not to harm.” In the modern day, iatrogenesis may occur at multiple points during interactions between patient and health professionals, ranging from diagnosis and prevention to surgery and follow-up.

For this book, the authors define iatrogenicity as any intentional or unintentional, immediate or postponed, yet preventable or avoidable harm to the human body or mind by either action or inaction (failure to prevent) of the medical caregiver (e.g., nurse, physician) resulting in discomfort, injury, disability, or death. Just as white light has seven component colors when passed through a prism, the concept of iatrogenicity has seven inherent components.

1. Any intentional or unintentional …

Determining intentionality is not a requirement in deciding whether harm is of iatrogenic origin because whether it was intended does not matter. It is important not to get lost in subjective conclusions or motives about whether a physician had malice in choosing and executing a treatment. Thus, accidents are included just as errors, misjudgments, side effects, and unexpected adverse events are.

2. … immediate or postponed …

Timing can be subjective and open to interpretation. For one person, medical harm might be clearly attributable to delay of care, while another might deem it prudent to wait and try other avenues of treatment. Fortunately, physicians are trained to justify their decision-making process, and it is understood that not all may agree. The point is to acknowledge that timing itself can be a source of iatrogenicity. This includes delay of care, delay of diagnosis, postponed decision making or appointments, or even treatment and diagnosis rendered too quickly.

3. … yet preventable or avoidable …

Preventability or avoidance is key to iatrogenicity. Can side effects or adverse events be prevented or avoided? Preventability is a challenging notion because physicians treat according to the practiced standards of care—standards that often have difficulty keeping up with the latest evidence-based practices, and can sometimes become outdated or even dismissed as poor practice. Current practices may be considered barbaric in the future, just as past practices that were used inappropriately (such as bloodletting) are rejected today.

In a broad theoretical sense, the concept of iatrogenicity can be applied to any medical action or inaction that might debilitate the body, its organs or their functions, or the mind. As a rule, caregivers base their decisions and clinical judgment considering a risk-benefit analysis, in which the benefits of their action, or inaction, will intentionally overcome the associated risk, harm, debilitation, discomfort, and other iatrogenic complications of the presenting complaint.

There are exceptions to the rule. For instance, often cardiologists risk the potential long-term benefits of treatment with short-term necessities (e.g., use of diuretics in acutely decompensated heart failure, recognizing that diuretics are associated with increased mortality in chronic stages of heart failure). Another example of calculated iatrogenicity: how many oncological patients are “sacrificed” during, say, a five-year period of treatment with a life-threatening torsadogenic QT-interval prolonging antineoplastic agent to prolong the lives of 50% of them by one year?

Do poor outcomes necessarily equate to poor medical practice? Can iatrogenic consequences be completely avoided? No. While iatrogenic consequences should be avoided when possible, this is indeed why medicine is an art and not a pure science. The difficulty is that for every discomfort, today’s physician is armed with a suppressive treatment. Although the treatment may disguise and reduce the patient’s suffering, it is paramount to understand that medical treatment can have minor or major implications that push the patient in the opposite direction of cure, or health. Therefore, the heart of iatrogenicity is that medicine is a fine art, a practice of deciding, not according to an algorithm or completely objective formula, but according to the individual patient’s wishes, metabolism, and response.

A purely rational provider could prescribe something for the nausea, and then something else for the headache that results from the first medicine, and then something else for the vertigo that resulted from the second medicine, ad infinitum. Treating symptoms only, then, is clearly not an ideal solution. Thus, a good provider cannot be entirely rational, but also practice medicine as an art in order to decrease unnecessary iatrogenic consequences; that is, she would treat disease according to her best knowledge of the laws that govern health of the human body.

In medical decision making, there is an art to weighing reduction in suffering against benefit to the patient. However, in the real world, the two may be in conflict. Often, this leads to discussions and teaching moments (recall that the term doctor comes from the Latin word docere, to teach) between medical provider and patient/family, as the medical provider explains what can reasonably be prevented or not. The clinical discipline of iatrogenicity would assist in discerning what is preventable or avoidable.

4. … harm to the human body or mind …

Medical harm to the human body is often obvious and may include discomfort, disfigurement, loss of function, and so forth. Such harm may be measured both objectively (with laboratory and imaging tests, for example) or subjectively (via patient reporting, family observations, etc.), and are both equally valid when discussing iatrogenicity. Mental wellness, as compared with physical wellness, can prove to be more difficult to measure. Suffering through an adverse event is not only a physical process, but also a mental one, subject to the perception of the patient and/or caregivers. In addition to the emotional component of suffering, there is the more outright type of mental harm that can occur directly due to treatment, such as psychological crises and distress.

5. … by either action or inaction (failure to prevent) …

Although inaction is less understood than action, it is no less an important feature of iatrogenicity. Patients expect that providers will care for them completely within their scope. Neglecting to perform or request proper diagnostic exams is an example of providers absolving themselves of the responsibility in the unspoken contract (implied consent to treat) between patient and provider. When the provider is making the decision not to act, that is an act in itself.

6. … of the medical caregiver (e.g., nurse, physician) …

The medical caregiver is anyone who provides a medical intervention for the purpose, and hope, of restoring health. Healing covers a wide spectrum from complete cure and palliation to restoring basic life sign...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Contributors
• The Concept of Iatrogenicity
• Part I: Medical Harm
• Part II: Iatrogenicity of Cardiovascular Drugs and Cardiovascular Toxicity of Noncardiac Drugs
• Part III: Iatrogenicity of Diagnostic and Therapeutic, Invasive and Noninvasive Cardiovascular Interventions, Devices, and Surgeries
• Part IV: Iatrogenic Aspects of Sport Cardiology and Lifestyle Modifications
• Part V: Iatrogenicity of Dietary Supplements, Herbal Products, and Other Nontraditional Therapies in Cardiovascular Medicine
• Index