Iatrogenic Disability - A Critical
Issueby Christopher Brigham MD
Iatrogenic
disability refers to disability resulting from the actions of
health care providers. It is imperative in assessing
impairment and disability to understand the origin of reported
difficulties. Impairment is based primarily on objective
factors, whereas disability is a more complex
concept.
Illness behavior is often reinforced by the
behavior of the physicians, therapists, attorneys, family
members and others involved with a case. It is recognized that
iatrogenic disability is a consequence of inappropriate
diagnostic labeling, unnecessary diagnostic studies, and
inappropriate treatment. There may be problems with
"medicalization", e.g. providing a medical diagnosis to
explain subjective reports of discomfort that are not caused
by an injury or illness and the application of a medical
intervention to treat these reports. This contributes to
somatization by magnifying preexisting, benign discomfort,
providing a new disease attribution for it and therefore
results in iatrogenic disability. The false diagnoses of an
injury or illness can result in fixed illness attribution.
False labeling of a problem, e.g. providing a label of
greater severity than is supported by the facts, may result in
a conviction of a serious underlying problem and impairment.
This is particularly problematic with a problem attributed to
an injury, since it may reinforce an experience of anger. This
may be influenced by issues of secondary gain, such as
attributing current complaints to an injury as opposed to
other causes (physical, behavioral or psychological),
providing a payment mechanism for medical and therapy and
services, permitting one to be less active or not having to
work on a full-time basis, receiving financial awards, and
obtaining the attention of others.
In some cases, it appears that some treating providers may
not be aware of pre-existing problems (physical and
psychological) or perhaps at times may not raise questions
which could potentially jeopardize their ability to be paid
for the treatments they provide. Issues of "false
attribution" may be seen among many participants in the
workers' compensation and personal injury arenas, including
with patients and their care providers.Diagnostic studies should be performed only
when they will result in information that is needed to manage
the patient correctly. Not all of the diagnostic studies
performed in this case are consistent with current, accepted
practice guidelines. Unfortunately, the performance of
inappropriate studies can result in iatrogenic complications.
For example, an imaging study of the spine may reveal findings
of degenerative disease, a common finding among asymptomatic
individuals. The patient, however, may perceive this as a
significant issue. This may result in false concerns, unneeded
treatment and incorrect assessments of impairment and
disability.
Treatment must be designed to improve the
functional well-being of the patient. For example, it is
recognized in the peer-reviewed medical literature and in
accepted practice guidelines that passive modalities (such as
ultrasound, electrical stimulation, massage, manipulation, and
injections) should be time-limited to the acute management of
an injury (e.g. up to four to eight weeks). As early as
possible treatment should reflect an active functional
restoration approach. Inappropriate care may be detrimental to
the individual by reinforcing dysfunctional behavior. Care
must focus on improving an individual's likelihood of
returning to a productive life, rather than services that are
likely to promote more prolonged disability and diminish the
individual's opportunities in life.
In assessing
impairment and disability consider the possibility of
iatrogenic impairment and disability. The associated costs,
human even more than financial, are high.
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_______________________
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