Latrogenic D Isease A

latrogenic D isease A. E. SOMERVILLE, MD latrogenic disorders are not necessarily symptoms of poor practice, but often unavoidable consequences of modern methods of therapy. This article describes some of the avoidable consequences. Dr. Somerville is chief of medicine at Saskatoon City Hospital and clinical assistant professor of medicine at the University of Saskatchewan. I ATROGENESIS IS becoming one Iatrogenic disease can be defined as the etiological agents to the patient, of the major problems of our pro- any dysfunction, disorder, or un- and of the apparent shortcomings of fession. But its scope and extent are toward reaction that may befall, or the doctor-patient relationship when not as widely and fully appreciated develop in, a patient as a result of he compares his own experience within the profession as one might visits to, or programs of investigation against the superhuman performance expect - even though the average and treatment by a medical practi- of TV's Welby or Kildare. practicing physician is likely to en- tioner. The disorder may be physical The thalidomide tragedy of a counter examples of it almost daily. or psychological, major or minor, decade ago effectively focused, as A spate of papers published in the transient or permanent. nothing before or since has done, the last decade generally concur that one Some persons have suggested that it public's attention upon the vector role in 20 patients, or five percent of is justifiable to include as iatrogenic of the physician. The popular press hospital admissions, is hospitalized any psychological or physical condi- continues to remind the public of this because of iatrogenesis, and that one tion induced by reading, or listening to in such articles as "A Hospital Stay patient in five, or 20 percent, will medical items and programs in the Could Be Fatal" which I clipped from experience during the course of hospi- various news media. Introspection may a newspaper recently. Those of you talization some type of adverse re- convert what is heard, seen, or read who have Life subscriptions in your action as a consequence of investiga- into neurosis; persuasive example may office waiting rooms may have read, tion and treatment. lead to self medication, or failure to with as much interest and concern as The term iatrogenesis is derived follow prescribed medical advice, with your patients, the recent article on from the Greek iatros (physician, or physical illness resulting. To my way heart transplants. surgeon), and the Roman genesis of thinking, however, this is too all- One should not, however, assume (production). Since men of medicine encompassing a definition, although that iatrogenic disorders always stem began to practice their art, or science we as medical practitioners may be from malpractice, or poor practice. In (depending upon one's viewpoint), it held to be lax, or derelict, in the many instances they are unavoidable has been clear that they had the performance of our professional consequences of treatment; in other opportunity, and position, to in- obligations when we do nothing to instances, they are unforeseen, or un- fluence the fate of their patients. A refute misleading medical articles and foreseeable, consequences of treat- tradition of conservatism in medical programs. ment. In too many cases, unfor- practice has understandably grown up Man has always had a consuming tunately, careful reflection, or selec- in the centuries since Hippocrates interest in his own wellbeing, although tion, might have prevented or admonished his disciples, "Primum the steps which he may take to ensure minimized a problem. Therefore we non nocere" (first, do no harm). Man that wellbeing are often in a sideways, cannot take a casual or disinterested also has long been aware of the if not in a backwards, direction, from attitude to a problem situation of this hazards of the doctor-patient relation- the physician's viewpoint. Never be- magnitude. Where that problem is ship, as well as the benefits. Napoleon, fore, however, have his expectations foreseeable and predictable, the when advised to consult his physician, been higher than in this era of well- patient must be forewarned; where allegedly declaimed, "I do not want publicized technological and pharma- satisfactory alternatives exist, these two diseases - one nature-made, one ceutical advance, and never before has must be used; where experience is doctor-made", and marched off he been more aware of the role of the new, this should be passed on to one's instead to Russia. physician as a vector who transmits colleagues. CANADIAN FAMILY PHYSICIAN/JUNE, 1972 85 Fisher, in an article in CMAJ tendencies become dominant in a mantle of humanity and compassion, (November, 1968) pointed out that profession, creativity is stifled and if not of humility, after he becomes routines established for the protection progress blocked. The implications are the servant of the ailing public and the of patient, profession and institution probably more serious in medicine guardian of the sick. had to be logical and thoughtful in than in any other profession since Robert Moser's book, Diseases of purpose and practice. He also quoted a objectivity and self-criticism are the Medical Progress - A Study of truism that allergies to naturally lifeblood of practice and investigation. Iatrogenic Disease exemplifies more occurring substances are uncommon, Where candid scrutiny does not exist, clearly than the spate of articles in the but that allergies and adverse reactions experience deteriorates into an exer- medical literature, the steadily widen- to the mass of synthetic or semi- cise of limited successes and repetitive ing horizons of iatrogenic disease synthetic drugs now in use are becom- errors within limited therapeutic resulting from the use of diagnostic or ing increasingly common and recog- horizons. This perspective explains, I therapeutic measures. The third nized. With over 7,000 brand prepara- hope, the vital importance and neces- edition of this book has grown to a tions to choose from, and an increas- sity of recording the clinician's volume of 985 pages, with 14 con- ing array of sophisticated diagnostic failures, mistakes, and adverse re- tributors aiding the author in his procedures, it is little wonder that the actions - as well as his successes and exposition, and its 16 chapters extend- modern physician frequently finds triumphs. Unfortunately, such honest ing from antibiotic-induced diseases himself in difficulty. appraisal and reporting leave the pro- through those related to several organ Sometimes, this position is of his fession open to headhunting by those systems, hormone-induced disease, own making; occasionally it is forced with preconceived prejudices, those connective tissue disorders, surgically- upon him. Those of you who recall seeking fame via the purple prose induced disease and those related to your pharmacology lectures at medical route, or those seeking fortune diagnostic procedures, concluding with school, or who are interested in old through litigation. a chapter on psychosomatics. medical textbooks, may recall a In the not too distant past the The reference lists for each chapter certain amusement and disbelief in doctor with the most opportunity for run into the hundreds. Antibiotic contemplating the polypharmacy of inflicting iatrogenic disease upon his therapy is considered in its side-effects herbal days. Unfortunately, we are patients was the surgeon. Within the of direct toxicity, hypersensitivity, seeing a resurgence of polypharmacy last quarter century, however, the role and its biologic effects in permitting in this age of potent synthetic and has reversed, with the physician having overgrowth of other organisms often semi-synthetic agents many of which the dubious distinction of being the resistant to treatment. The congenital have not been available long enough main potential instigator of unneces- effects of drugs transmitted through for the incidence and extent of side sary and unwanted morbidity (and the placenta run the gamut from effects and adverse reactions to be mortality) in the medical community. tobacco, the teratogenic drugs fully appreciated. The cynicism and Consequently, those who prescribe (thalidomide) and the steroids. The amused contempt with which we read and administer physic must become author points to the 'deliberate risk' those old prescriptions containing as fully conversant with any drug they the doctor takes in prescribing drugs many as 12 or more items, should be prescribe,. and must know the inter- for a pregnant women, and points to balanced by an equal concern and actions of combination therapy. At the safety of avoiding the use of new careful evaluation of today's hospital the same time, the public health drugs during pregnancy. In the derma- patient on a dozen or more different section of our profession, the re- tological field the drug eruptions, medications often containing agents searchers, and the medical educators, intolerance, and toxicity are seemingly with diverse, contrary, or potentiating must accept some share of the blame without end, while the photo-sensitiz- properties and actions. for the present day situation. The ing drugs are of special interest. The Polypharmacy is not necessarily a medical educators, in particular, must chapter on iatrogenic gastrointestinal phenomenon of the doctor's making. bear some of the, blame, albeit in- diseases is of particular significance in It is often a product of excessive direct, for the growth of iatrogenesis. the relationship of drugs to serious demands placed on him by the public, The attitudes acquired in medical hepatic disease. Nearly 400 references and by man's strident demands for the training are those carried into practice. to the chapter on iatrogenic hema- better life in all things (including The budding physician of today is tologic disease indicate the wide escape from the unpleasant realities of nurtured all too frequently on elec- spectrum of the ill-effect of drugs on day-to-day living). The same people tronic devices, multiple investigations, the bone marrow and the red cells who strenuously protest the un- and therapies.

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