Iatrogenic diseases are those induced by physicians and surgeons themselves and may consist of any untoward effect on a patient resulting from actions of healthcare professionals. Causes of “iatrogenesis” include: a) side effects due to possible drug interactions, b) complications arising from a procedure or treatment c) medical negligence, d) and unnecessary treatment for profit. The role of medical miscalculations can be multifarious. While many are non-consequential, an error often can end the life of someone with a long life expectancy or accelerate an imminent death.
A very common iatrogenic effect is caused by “drug interactions”. The emergence of “superbugs” and the surfacing of frightening “antibiotic bacterial resistance” are also iatrogenic. But, unlike the above, certain drugs like anti-cancer drugs are toxic in their own right because of their mechanism of action and here the physician may not be always culpable.
Errors by doctors are inevitable since doctors are human. But the design of safer systems can mitigate their frequency. Strategies to reduce death from medical care should include three steps: making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account. It is imperative that we create a culture whereby we learn from our mistakes to advance the science of safety in medicine.
We deal after all with humans and clearly nothing is black or white here since no two human beings are ever the same. Chest pain, for instance, may be a “coronary pain” and if you miss an early diagnosis it can be fraught with grave consequences. But that doesn’t mean that every pain in the chest is due to heart. An overdiagnosis, for the fear of making a mistake, has resulted in a legion of “cardiac neurotic cripples”. First and foremost, doctors must exercise their clinical sense, then complement as required with ancillary tests without exaggeration and overburdening the patients unreasonably.
Sadly, deaths caused by medical errors go unmeasured and discussions about prevention occur in limited and confidential forums, such as internal morbidity and mortality conferences. These forums review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department.
A new study published in the BMJ (British Medical Journal) says that if ‘medical error’ was a disease, it would be the third largest killer in the US. The BMJ study, conducted by a Johns Hopkins University team, for the first time, measures the contribution of medical errors at 2.51 lakh annually in US. In India approximately 3 million years of healthy life are lost due to medical errors, according to a Harvard study done in 2013.
Dr Anirudha Malpani writes, “While it is true that all doctors make mistakes, it is equally true that most of us regrettably refuse to discuss them. Medical mistakes have always been shrouded in a conspiracy of silence and this was important because it was necessary to give patients the impression that doctors were infallible. Such a strategy may have been appropriate in the past, when doctors had few effective tools in their armamentarium and trust in the doctor was a vital element of the healing process. Blind faith in the doctor was encouraged to keep the doctor on his pedestal with an aura of rectitude around him”. But things were bound to change and, luckily, for our patients, they are changing.
One of the first principles in medicine is “Primum non nocere” (first do no harm). It is therefore strange that we talk so little about iatrogenic problems. Since we often prefer to ignore, overlook or cover our mistakes we never learn from them. All of us know what it feels like to make a bad mistake. You agonize about what to do, whether to tell anyone and what to say. Later, the event replays itself over and over in your mind. You know you should confess, but there’s a nagging fear of being discovered. But one thing is true: making a mistake can be forgiven; not taking action to prevent its recurrence is unforgivable.
In my personal experience people often castigate me for being “overcritical”. However most of my colleagues take my “reprimands” in the right spirit. Once, when I passed certain “warranted” remarks against a local Corporate Hospital, its non-medical “Sumo Pontífice” reacted irately and publicly stating that he “felt ashamed that I was pointing an accusing finger at members of my own community”. He was wrong, first, because I had not singled out anybody – only the “Corporate” as a whole. Then – I ask – if doctors will not act as watchdogs of their own profession who will? This is something non-medical people who lord over corporate hospitals (and are more worried about monetary returns) will never be able to grasp. I confess I am a most fallible man. But, while I try to put my own house in order, I presume, as a senior member of my profession, I do have the right to indulge in some amount of constructive criticism.
Finally, here’s a “prescription” for us, as doctors, to deal with medical mistakes: a) Accept responsibility for the mistake, b) Discuss it with colleagues, c) Apologize to the patient, d) Make changes to reduce errors in the future.
“Errare humanum est, sed perseverare diabolicum”.
(Dr. Francisco Colaço is a seniormost consulting physician, pioneer of Echocardiography in Goa)
