"Iatrogenic disease": the view from up close

Here is a frightening statistic: an article published in the year 2000 in the Journal of the American Medical Association calculated "that between 230,000 and 284,000 deaths occur each year in the US due to iatrogenic causes, or physician error, making this number three in the leading causes of death for all Americans."* That's a quarter million Americans dying each year due to hospital mix-ups, adverse drug reactions from prescriptions drugs, hospital-acquired infections and botched surgeries. Quite a number to swallow: the equivalent of about five hundred 747s crashing every year, killing all passengers on board. And this number does not even included those are not killed by the error, but "only" maimed.

[Now you can also read "Iatrogenic disease - Part 2"]
My mother was only 51 when she died a few short hours after her first radiation treatment for a recurrence of breast cancer. Her tests showed her to be cancer free when her oncologist, whom she said she "trusted with her life", suggested "prophylactic radiation". She was on Tamoxifen, implicated in causing blood clots, and had to have the radiation rescheduled because her chest cavity had been "mismeasured". A second such mismeasurement could have led to radiation burns in her lungs, edema, and death. Yet there was no inquest into her unexpected and untimely death.

The mother of a friend of mine has had repeated, and devastating, experiences with iatrogenic disease. She was already suffering from Alzheimer's when she was diagnosed with a particularly deadly form of lung cancer. Her doctors were 99% sure she had this cancer and recommended surgery. So deadly was the cancer believed to be that they recommended against doing a biopsy. She had the "cancerous" lung removed. She then went into full-blown dementia as a result of the stress of this horribly invasive surgery. When the lung was sent to the lab, it turned out that what the doctors believed to have been cancer was in fact scar tissue from a bout of pneumonia. There was no cancer.

Fast forward a few years. Once again a doctor saw something he suspected to be cancer; this time skin cancer. He proposed doing multiple biopsies. The woman's daughter raised objections, which the doctor overrode. Two days after the biopsies were done, the elderly patient became septic. No antibiotic seemed able kill the bacteria raging through her system. By the time the infection was finally brought under control, the patient had lost the will to live and passed away.

Not all these patients die; some are "merely" maimed for life. While they don't become part of the statistics on medical error causing death, these instances cost untold amounts of money to an already overburdened system. First there is the cost of the initial, often unnecessary, intervention, then there is the cost of trying to fix the mistake, and then there is, in the case of younger patients, the economic loss when the victim becomes so disabled that he or she is no longer able to work.

And more important than cost is the burden of suffering, borne largely by the elderly. In my mother's case the judgment of a doctor ended up costing her her life, but at least her death was quick and relatively painless. My friend's mother's case became a textbook example of what Bill Bengston bluntly calls "torturing [the elderly] on the way out."

Simply put, what is the benefit of doing a biopsy for basal cell carcinoma on an elderly woman suffering from Alzheimer's? What is the benefit of doing a double mastectomy on an 86-year-old patient with a slow-growing cancer who then dies of a stroke less than a year later? How many painful procedures should the elderly have to endure? Shouldn't we ask, how necessary is this? Shouldn't we do a humane cost/benefit analysis as in "how much suffering is this going to cause? how likely is this to harm/benefit the patient?" This is a discussion that should take place in every single case, possibly in the presence of a medical ethicist or a professional who specializes in elder care. Many doctors are way too "intervention happy". If the only tool you have is a hammer, then you see everything as a nail. If intervention is the only tool in your toolkit, that's all you will do. Family members can also buy into the medical mystique and believe that more intervention is better, until their loved one comes to harm. In many cases palliation and alternative therapies offer better outcomes.

A study published in the New England Journal of Medicine in 2010 showed that lung cancer patients who received palliative care along with conventional treatment lived longer and had better quality of life than patients who received conventional cancer treatment alone. The study "showed that people who received the palliative support services were less likely to choose aggressive, and often futile, measures to prolong their lives." In contrast I recently heard a doctor say in an interview on CBC that he sees more and more advanced cancer patients going from chemotherapy straight to the ER, and then from there to the morgue, as many doctors prescribe more and more aggressive treatments. This is definitely "torturing them on the way out", and it's questionable how necessary it is.

Obviously no doctor or other medical professional does a procedure with an intent to injure. But the truth of the matter is that cookie-cutter medical protocols applied or mis-applied to unique human bodies will result in at least some of them being harmed when things go wrong. Should we continue to accept this "collateral damage" as part of the business of practicing medicine in North America?

Postscript Sept. 26: And now see this NBC article, which estimates that only about one percent of events that cause harm to patients are reported by hospitals and asks why patients themselves are reluctant to report medical errors.

And also this: The Drugs Don't Work, an alarming expose of how drugs are approved.

And now the medical perspective: