Prevention vs Iatrogenic Harm
THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 10 - OCTOBER 2021
In medicine, when we see something awry—or even something that might go awry—we tend to fix it. But can this tendency create its own problems? A friend's recent experience got me thinking about the fine line between preventive medicine and iatrogenic harm.
My friend had a routine colonoscopy, during which physicians found and removed a benign polyp. A week later he developed lower-GI bleeding. He fainted in the middle of the night, fell in his bathroom, chipped a tooth, and bruised his head. He awoke lying on the floor.
In the morning he called me, and I drove him to the local emergency department. My friend's hematocrit was 31. An ECG showed abnormal T waves, and the attending physician was concerned about myocardial ischemia and called the cardiology resident. They began to discuss admitting my friend to the ICU, but, after reveiwing a previous ECG, they realized the findings were preexisting.
Later that day, my friend endured a repeat colonoscopy to place two clips at the source of bleeding where the polyp hade been removed a week earlier. He spent the night in the hospital. I sneaked in a little wine and some chocolate to cheer him up and to celebrate the fact he didn't end up in the neuro or cardiac ICU.
Following the episode, I began to consider more carefully the fact that even preventive procedures are not without risk. Apparently, the risk of lower-GI bleeding following colonoscopy is about 1 in 200. In my friend's case, his routine colonoscopy ended up with a 4-g Hb loss, a chipped tooth, a minor (fortunately) head injury, an admission to the hospital, a near-admission to the ICU, and a repeat colonoscopy.
In 120214, Siscovick et al1 compared the risk of sudden cardiac death during exercise to the overall benefit of exercise for lowering the risk of sudden cardiac death. He found a crossover point that supported regular exercise as more beneficial than no exercise, even though it slightly increased the risk of death during exercise.
A few years ago, the Institute of Medicine documented the risk of medical error and iatrogenesis. The "first, do no harm" principle remains true even in preventive medicine. And, as we place a greater emphasis on prevention, we will need to hold on to this principle as we better define the crossover point between prevention and iatrogenesis.
The part of our profession that promotes exercise as improving health is preventive and low risk. And it can be argued that, several decades ago, sports participation itself was relatively low risk. But sports are now much more competitive, and, with more participants, procedures to treat sport injuries have increased.
Since the culture of treatment in sports medicine has absorbed urgency as one of its dominant principles, speeding the return to sport has become foremost in the athlete's mind. As a result, the threshold for surgical intervention is lower in competitive athletes. Thus, it is important to keep in mind that the risks associated with procedures in which the main indication is return to sport are real and should be weighed against long-term health.
In the end, my friend did fine. One week later he completed three hikes in the Rockies with lengths between 3.5 and 7 miles and vertical elevations between 1,000 and 2,300 feet. But he isn't exactly looking forward to his next "preventive" colonoscopy.