Adam Tufts: A Systematic Approach to the Invisible Epidemic of Iatrogenesis
The story is simple. An unassuming patient waltzes into the doctor’s office. After months of their dentist harping on them, they’ve finally carved out time to make a wisdom tooth removal appointment. It’s a routine procedure. So they enter the waiting room, their mind at ease. Why would they worry? After all, they are surrounded by professionals who have undergone years of the most rigorous training and have spent even more time afterwards accruing experience with previous cases. The patient is called into the operation room. All is calm. Then the surgeon starts to perform.
Heart rate drops inexplicably. Hypoxia rears its ugly face. The patient is quickly losing brain functionality. Quick movements. Rushed commands. Bated breaths. Silence. The patient awakens, but a shell of who they used to be. Their slowed heart rate deprived the brain of so much oxygen that the damage is irreversible. A week later, complete brain death is pronounced. This specific story belongs to a 17-year old girl named Sydney Galleger (ABC News 2017). But there are so many other unfortunate and tragic cases that trace a parallel arc to Sydney’s.
Indeed, iatrogenesis, or medically-induced harm, accounts for five to eight percent of deaths worldwide (Peer and Shabir 2018). In several countries it even earns the title of leading cause of death (Peer and Shabir). And for the United States alone, it is estimated that medical error claims the lives of more than 250,000 individuals each year (Johns Hopkins Medicine). Not to mention, these figures do not even begin to touch upon the countless many whose existences have been fundamentally disrupted by chronic injuries and conditions they have incurred at the hands of medical practice. Yet despite these chilling numbers, iatrogenesis has largely failed to achieve an even comparable level of notoriety to some of its counterparts, with afflictions such as heart disease, cancer, and influenza never leaving the tongues of the medically conscientious. Oftentimes, iatrogenesis is not allotted its own category in displays of public health death statistics, either pigeonholed under the overly broad umbrella of “preventable injuries” or erroneously attributed as some other cause (i.e. “heart disease” if the medical harm occurred at any point in the treatment of a heart problem). Whether this public perception of wide scale iatrogenesis is a symptom of apathy or neglect is not immediately clear. What is clear is that the problem is burgeoning and people, en masse, are looking the other way.
Although, this is not to say that iatrogenic occurrences have not garnered attention at an individual level – in the past decade, the nation has watched malpractice cases rise with unseen rapidity (Gallegos). Now, more than ever before, patients are likely to react to iatrogenesis by launching a legal battle against their provider. This increase may be inspired by heightened awareness of physicians’ faults or by the ever-heftier settlements that victimized parties are coming to receive. Notwithstanding, the premise holds that people are more conscious than ever of missteps in their personal medical care. In accordance, the patient-doctor relationship seems to tout a novel hint of opposition and ferocity. Patients are announcing their newfound commitment to self-advocacy; they will no longer be the mere ground over which the medical system plows. Physicians, in turn, are readying their defenses, surging to find the optimal malpractice defense teams and insurance plans. This all accompanies a marked shift in the physician-patient relationship, from a paternal mode of care to a tug-and-pull decision making process between provider and patient (Chawla). At least in these direct one-on-one relationships, the patient seems to be more involved, and invested, in their medical treatment plans than ever.
Thus, I present a portrait of the medical system that brims with paradoxical colors and shaded nuance. At once, the American population cares so little and the American individual cares so much. At once, medicine heals us and kills us. At once, physicians heed to a medical system rooted in decades-old precedents and patients look forward to a medical system that does not yet exist. The landscape of medical care in America has become fraught with incongruity, discord, and, most notably, danger. So, where are we erring? Why are so many people dying and getting injured in the care of a system meant to heal? The answer I begin to offer transcends the blunders of individual physicians and the grievances of individual patients. It grapples with iatrogenesis as a systematic dilemma, as an epidemic rather than a series of individual events. I argue that a systems-based approach is critical in addressing the urgent crisis that is iatrogenesis.
Our first priority, societally, should not be the condemnation of specific physicians for their shortcomings, nor the isolated accidents that befall hectic settings such as hospitals. We must, instead, seek to unroot and stifle primary causes of iatrogenesis. I say this because a purely reactionary mode of medical harm mitigation is ineffective and misguided. To watch a doctor fail in the operating room, to watch the life slip from a patient with a treatable ailment, is heart-wrenching and terrible. But if we truly seek to aid these patients, it is paramount that attention is directed towards the fundamental causes of these medical missteps rather than the particular missteps themselves. A reactionary response to iatrogenesis applies a short-term fix (if that) to a long-term problem.
We see this sentiment supported in sociological and bioethical literature. Measures such as innovative safety technology and revised patient information protocols have been shown to affect an appreciable decrease in incidences of clinical iatrogenic harm (Yang et al.) Similarly, risk assessment tools which aid in the identification of patients who would face the greatest risk for particular procedures have engendered similar effects (Yang et al.) Notwithstanding, cultural attention is focused not upon this systematic approach to the mitigation of iatrogenesis. Some of this might be due to the heightened emotional investment people have in individual iatrogenic events rather than the issue at large. Iatrogenesis certainly crescendos in significance when it enters our own personal lives; otherwise, it remains shrouded in statistical discussions and becomes a problem solely relegated to circles of public health officials.
This tendency to prioritize causes close to oneself is a proclivity so deeply human in nature. We are undeniably best moved by affective influences. Just look to the world of activism as evidence: the vast majority of cancer activists report that their lives have been profoundly touched by cancer at some point, the same holds for most social injustice activists (Cox). Tying this back to iatrogenesis, it becomes evident why people are coming to care so deeply about failings of the medical system within their individual experiences. Personal histories, like that which opened this article, are simply more compelling than matters which assume a broader, nationwide, scale. So, influenced by these personal experiences, people are most likely to respond to only these individual occurrences, rather than the issue as it is widely understood.
Yet irrespective of this elevated personal awareness, rates of clinical iatrogenesis have not decreased in the past decades (Hartford Institute for Geriatric Nursing). This is because to attack the errors of specific physicians is to attack human error, and to err is an unyielding facet of human experience. No matter how many years of training we demand from our doctors, no matter how many examinations we set for them to pass, error will occur. Rather than attempting to quench the stubborn and inevitable fact of human fallibility, we must construct nets and protocols which mitigate the consequences of such mistakes. We should seize the variables which are truly beneath our control. This might look like a rethinking of hospital safety protocols, as aforementioned, or policy initiatives which construct additional barriers of defense between the patient and instances of iatrogenesis. One such policy initiative which has gained notable prominence is the Patient Safety Act, which emboldens providers to voluntarily collect information pertaining to patient safety and health care quality (Federal Register). This data is then analyzed and aids in the formulation of policies and protocols that would be most advantageous towards ensuring the perpetual safety of the patient (Federal Register). In fact, this strategy of tackling medical error by constructing manifold layers of safety has been coined by past public health professionals as the Swiss Cheese Model (Perneger). The premise is that no one medical safety measure will be completely effective (they will have holes in a manner akin to swiss cheese). So, through the implementation of numerous safety nets, we can ensure the highest potential of safety for patients.
However, it is critical to note that none of this systematic reworking of healthcare safety should come at the cost of individual physicians’ quality of care. The standards which we hold doctors to should not be relaxed – rather, we should make sure to optimize the safety protocols which are enacted in the cases in which these standards are not met. Patients are absolutely entitled to assume agency over the healthcare they receive. I merely contend that there are factors beyond a myopic perception of healthcare safety that are worth considering – and fixing. No magical salve can be placed on the problem of human error, so society must reorient itself in a manner which it has not yet; people must view iatrogenesis as the societal, not merely individual, threat it very much is. It is through this broad-scale recognition of iatrogenesis that we will begin to render practical and effective solutions to the phenomenon currently harming so many.
Adam Tufts is a Sophomore at Yale University in Berkeley College
Citations:
ABC News.“Parents of Teen Who Died after Getting Wisdom Teeth Comment.” ABC News, ABC News Network, 5 Dec. 2017, abcnews.go.com/Health/parents-teen-died-wisdom-teeth-pulled-accept-2m/story?id=51571376#:~:text=Sydney%20Galleger%2C%2017%2C%20went%20into,arrest%20during%20the%20dental%20procedure.&text=%E2%80%94%20%2D%2D%20A%20Minnesota,November%2C%20according%20to%20court%20papers.
Chawla, Sheetal. “The Evolution of the Patient-Physician Relationship.” Physicians Practice, 11 January 2023, www.physicianspractice.com/view/the-evolution-of-the-patient-physician-relationship.
Cox, Holly. “What Motivates Us to Engage in Activism.” The Commons: Social Change Library, 14 Aug. 2023, commonslibrary.org/what-motivates-us-to-engage-in-activism/.
Gallegos, Alicia. “Mega Malpractice Verdicts against Physicians on the Rise.” Medscape, 2 February 2024, www.medscape.com/viewarticle/mega-malpractice-verdicts-against-physicians-rise-2024a10002bz?form=fpf.
NYU. “Iatrogenesis.” Hartford Institute for Geriatric Nursing, New York University, hign.org/consultgeri/resources/protocols/iatrogenesis. Accessed 23 Apr. 2024.
Newman-Toker, David E, et al. “Burden of serious harms from diagnostic error in the USA.” BMJ Quality & Safety, vol. 33, no. 2, 17 July 2023, pp. 109–120, https://doi.org/10.1136/bmjqs-2021-014130.
“Patient Safety and Quality Improvement Act of 2005-HHS Guidance Regarding Patient Safety Work Product and Providers’ External Obligations.” Federal Register: Daily Journal of the United States Government, Agency for Healthcare Research and Quality, 24 May 2016, www.federalregister.gov/documents/2016/05/24/2016-12312/patient-safety-and-quality-improvement-act-of-2005-hhs-guidance-regarding-patient-safety-work#:~:text=The%20Patient%20Safety%20Act%20promotes,health%20care%20outcomes%20to%20PSOs.
Peer, Rafia Farooq, and Nadeem Shabir. “Iatrogenesis: A review on nature, extent, and distribution of healthcare hazards.” Journal of Family Medicine and Primary Care, vol. 7, no. 2, 2018, pp. 309–314, https://doi.org/10.4103/jfmpc.jfmpc_329_17.
Perneger, Thomas V. “The Swiss Cheese Model of safety incidents: Are there holes in the metaphor?” BMC Health Services Research, vol. 5, no. 1, 9 Nov. 2005, https://doi.org/10.1186/1472-6963-5-71.
Yang, Jian, et al. “Understanding the effects of iatrogenic management on Population Health: A Medical Innovation Perspective.” China CDC Weekly, vol. 5, no. 27, 7 July 2023, pp. 614–618, https://doi.org/10.46234/ccdcw2023.118.
