Iatrogenic Disability -- A Critical Issue

Saturday, September 8, 2007 | 0

By Dr. Christopher Brigham

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.

It is not always clear whether the providers involved in the care have been unaware of the pre-existing status and psychological background of the examinee, have failed to document these significant issues, or have chosen, for one reason or another, to ignore these significant issues. In some cases, it appears that some treating providers may not identify significant pre-existing problems so as not to 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.

Dr. Christopher Brigham is the editor of the Guides Newsletter and Guides Casebook. To view more of these tips visit:

www.impairment.com/tips

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