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Iatrogenic Disease in General Medicine
VOLUME VII - NUMBER 3
MAY-JUNE,1966
rsyc BIOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Iatrogenic Disease in General Medicine H. ISIIIKAWA, H. OHTSUKA and M. AOKI
• A study was attempted to clarify the nature of iatrogenic disease as ohserved in the practice of general medicine. The adjective "iatrogenic" stems from the word (iatros- - physician and genes - caused by) and was originally used hy Sir Arthur Hurst. It is a "term applied to disorders induced in the patient hy autosuggestion hased on the physician's examination, manner or discussion".' However, in recent years, the term "Iatrogenic Disease" has extended its meaning to include illnesses caused or aggravated through medical treatment, mainly drugs, and also those which are caused by suggestions made through mass media. In this study, the term was limited to its original meaning and to neurotic and psychosomatic reactions caused by the physician's words or hehavior. Interpretations concerning the definition of iatrogenic disease have been discussed hy many.~·" At the Sixth ConVl'ntion of the Japanese Society of Psychosomatic Medicine ( 1965), the definition was limited to tIl(' original in the symposium on "Iatrogenic Diseases." In conclusion, Dr. lkcmi (chairman) suggested the necessity of defining its term to the original to avoid ohscurity in its use. He also pointed to the fact that the physician's words or behavior often act as a "trigger" in the development of the disorder to the patient who is already in a prepared state to react. From the Fourth Department of Internal Medicine. Faculty of ~Iedicine, The UnivNsity of Tokyo and the Health Counselling Unit of the Tokyo University Branch Hospital, Tokyo, Japan. May-June, 1966
Studies concerning the mechanism hy which the disease develops, such as that of "'heeler' and Hart,'-' have suggested that the prohlem not only lies in the physician alone hut also on other factors. Kanehisa'; has reported on "iatrogenic neurosis" and the role of the physician in the social interaction with the patient. In considering the complexity of the mechanism by which the illness is caused or aggravated, it was postulated that there must be multi-causative factors in its occurence and not a simple "cause and result" relationship. From the ahove postulation that the genesis of iatrogenic disease is not caused hy a single factor, we have attempted to analyze the process in medical practice hy following the patient through from tIl(' time he perceives his unusual hody feeling to the point where the doctor reaches his diagnosis. In other words, to follow through the process of transfer of information between the two parties and to find the flaw in medical practice itself. (Fig. 1.) A general hody feeling exists in all persons. The normal individual too is suhject at all times to somatic sensations slightly helow the level required to claim the attention of consciousness.; These sensations, pass unheeded and usually do not form the suhject of complaint. However, when there is a moment in which the attention of the person is drawn to the condition of the hody, these sensations secure conscious appreciation and are felt to be the sign or symptom of dysfunction or abnormality of the body. The process
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131
PSYCHOSO\IATICS
Process of Communication in Medical Practice
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by which this perception hecomes apparent differs in every individual. The cause may he organic or functional. In interpreting this specific body feeling, the person's thinking process is founded on previous communicated facts which formulate the individual's medical knowledge. It may he through mass media, physician, family and other sources. Besides these, there is the basic character of the person, personality traits and milieu which influence its interpretation. \Vith these influencing factors, the patient integrates his thinking and comes to the doctor with his complaints. The doctor on the other hand, in accordance with the patient's report, makes his observation based on knowledge derived from medical science. Through examination and contact with the patient, his thoughts are integrated and a final interpretation is reached, which is usually the medical diagnosis. In communicating this interpretation to the patient, he is informed as being healthy or as having a specific disease. However, in certain individuals, because 132
of the difference in the integrating process, the understanding of the bodily condition may he of different nature and thus form a circuit hy which the information or suggestion given by the doctor becomes a stimulus and acts upon the perception of the patient producing a neurotic or psychosomatic reaction. The physician often does not realize the fact that diagnosis is not a one way process. He needs to recognize the fact that the process of diagnosis is a two way process in which the patient also participates and acts upon his own interpretation and arrives at a self-diagnosis. The recognition of this process is important. :I,IATEIUAL AlXD METHOD
The study was retrospective in design. The subjects were 50 in total: 30 hospitalized patients, 11 out-patients from the department of internal medicine and nine patients from the health counseling unit of the Tokyo University Branch Hospital. There were 21 males and 29 females. The range of age was from 20 to 60. The main disorders were: 14 cardioVolume VII
IATROGENIC DISEASE-ISHIKAWA ET AL
(Fig. 2) indicates the process in which the problem developed in general practice. 1. Problems created through the discrepancy in diagnosis. The problem arose when there was discrepancy of diagnosis made hy different physicians or by a single physician. The former was caused by the patient changing physicians at his own will, or by the attending physician referring his patient to another physician without taking on the final responsibility. In other words, it was the negligence of the attending physician to integrate and explain the results of the referrals that gave rise to unnecessary anxiety in the patient. The problem was also caused by one physician, when he carelessly changed the diagnosis without giving due consideration to the patient's feelings.
vascular, eight gastrointestinal, four neurological, one respiratory and three others. Twenty were completely free of organic disease. The analysis of the iatrogenicity was made through medical recordings of each patient and through interview. The criteria in determining the psychic manifestation were formed hy the psychiatrist and by us. RESULTS
As a result of the analysis made on the 50 patients, the iatrogenic factors were grouped under four major problems. 1. Prohlems created through the discrepancy in diagnosis. 2. i\'egligence of social and psychological prohlems. 3. Purely medical problems related to diagnosis and treatment. 4. Prohlems caused directly through inappropriate doctor-patient relationship. The four major problems were revealed through analysis in accordance to the aforementioned schema. The following schema
2. Negligence of social and pstjcllOlo{!,ical problemy. In some cases the social and psychological problems ohviously underlied the cause of the disorder. This factor was most prominent in patients of the hysteric type where the physician neglected to ohserve
Developmental Mechanism in Iatrogenic Disease
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PSYCHOSOMATICS TABLE J. I.
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A:-IALYSIS OF MAJOR IATROGENIC FACTORS
Problems created throu~h tht> discrt'pancy in dia~nosjs Discr('pancy made by one doctor.... Discrepancy made by more than one doctor... The paticnt ('han~in~ doctors at his own will...... 1rrc.'sl)Qnsible n·r('rrin~ to another doctor.... ~e~li.liten('(' nf !'locial and psycholo.'{ical problems.. _ Pu...·ly medical problems relaled to dia~nosis and Ireal-
I 6 2 4 3
lIu'nt
:\'Iisdia.litllosis
_...............................
0
Difficuhy in dt'tt·rminin.'C dia.litnosis.... Difficulty in clt·t('mlinin.lit mt'thod of treatment... -t. Prohlrms caus('d directly throu.lith inappropriate doctorpatient rrlationship Statt'ment mad(' to avoid takinli{ responsibility.................... Iliappropriah' statement madt· en'n wh('n ba.~ed on SOffit' _~r()unds
Indifft'f('nt statC'ml'nt made- without definite ~rounds.... l'nll('c('ssary usr or medical technical terms.. statemC'nL................. . NOl informinl{ known dia~nosis.............................. ACli,'c 1H'~li!l:('nc(' or patient's psycholo~·.... Inal>prolniale. t~('almenL...... . MedIcal CUTloslty................
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5
n 4
6 6 :\ 5 0
40 0
them on a psychological level and hence aggravated the course of the disease.
3. Purely medical problems related to diagnosis and treatment. This factor consisted purely of medical problems, such as difficulty in determining diagnosis or therapeutic plan. Because of the lack of explanation and psychological consideration in these cases, unnecessary fear and anxiety were exaggerated and influenced the course of the disease. 4. Problems caused directly through inappropriate doctor-patient relationship. The problems were created directly by words or behavior of the doctor. This consisted of threatening statements, use of unnecessary medical terms, irresponsible statement without grounds or inappropriate explanation even when based on some grounds, etc. The incidence of iatrogenic factors found in the .50 cases are listed in Table I. As indicated in the table. one or more iatrogenic factors overlapped in the majority of patients and in some there were many factors involved. In cases with organic changes, the mechanism by which the iatrogenicity developed was more complex.
feelings. It was not totally the fault of the doctor's response alone, but the patient's basic character and personality that influenced the development of the disease. It was found that environmental factors also play an important role. In cases with environmental difficulties, the patient either consciously or subconsciously desired to escape from his environment. The doctor's inappropriate words and behavior were utilized to rationalize his wish to avoid his difficulties, thus inducing an apparent secondary gain. Though the main cause may lie on the patient's part, it was also a failure on the doctor's part because he was unaware of such psychological mechanism and to have concentrated on examination at the physical level alone. Eighteen cases were found to have environmental problems greatly influencing the cause and course of the disease.
2. Neurotic types. In addition to the above factors, the type of reaction to the iatrogenic factors were studied and analyzed. As a result, the neurotic reactions were classified into four types (Table II). It was found that the hypochondriac type was most prevalent followed by the anxiety neurotic type and hysteric type. The phobic type was few in number and no depressive reaction was found among our cases. TABLE II.
~eurotic
Anxi('tv N('urotic Type
Hysteric TYI)e Hypochondriac Tvpe Phobic Type
Anxietv :\eurosis Anxiety Neurotic tendency Conyersion Hvsteria Hysteric character Hysteric tendency :"ervous Hypochondriasis Hypochondriac t('ndencv Phobia Phobic tendency TOTAL -
Cases with environmental problems
Ii
7
4 6
8
9
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2
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2 50
18
----------.
FACTORS
1. Personality and environmental factors. Among the 50 cases, 31 were found to have definite personality problems which contribute<1 to the development of the disease. Because of their neurotic tendency. they were hypersensitive in reacting to the doctor's words or behavior and also to their body 134
:"0. or cases
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:-IEVROTIC TYPES
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The relationship between the physical finding and neurotic type revealed that the hypochondriac type had the least organic findings among the 50 cases. As shown in Table III a number of our cases had definite or slight organic changes which increased the complexity of the mechanism by which the iatrogenic factors acted. Volume VII
IATROGENIC DISEASE-ISHIKAWA ET AL TABLE III. PHYSICAL FINDINGS AND NEUROTIC TYPE Anxie.ty
Neurotic Type
HY'teric Type
Hypochondriac Type
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15
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DISEASE SYMPTOMS A:>:D NEUROTIC TYPE Circulatory
CastrointesRespi· tina) Nervous ratory
system system system system Others TOTAL Anxiety neurotic
Type Hypochondriac Type HY'teric Type Phobic Type TOTAL
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The neurotic types were also studied in relation to the disease symptoms (Table IV), A circulatory condition was related to most of the anxiety neurotic type; manifestations in the nervous system were seen mostly in the hysteric type. These findings seem reasonable from the standpoint of characteristics in the symptoms of these conditions. Other disease symptoms were also observed. In analyzing the iatrogenic factors in relation to the neurotic type, it was revealed that the problem of doctor-patient relationship was most prominent in the anxiety neurotic type in comparison with the others. This problem was also prominent in the hypochondriac type and in addition, the problem of discrepancy in diagnosis was important in this type. In the hysteric type, in addition to the problem of doctor-patient relationship, social and psychological problems were eminent. It was interesting to note the characteristics in the relationship of neurotic types to somatic conditions and to the iatrogenic factors (Table V). The following case reports are presented to demonstrate the inter-relationship of causative factors. DISCUSSION
The iatrogenic factors were revealed through analysis of the process of communicaMay-June, 1966
tion in medical practice as described in our first schema. (Fig. 1) It was found that the problem of iatrogenicity is not caused by a single factor but is developed through multicausative factors. The patient seeks the help of the doctor because he becomes concerned with his unusual body feeling. His motivation for coming to the doctor is based on an ambivalent feeling of anxiety and expectation. He comes to find relief from his anxiety. The state of preparedness on the patient's part cannot be underevaluated. His predisposition, personality traits, environment and somatic condition greatly influence the development and course of the iatrogenic condition. The "trigger mechanism" caused by the doctor's words or behavior often precipitates the development of the condition. As revealed in the results of the study, the iatrogenic factors were found in the four major areas. In the problem of discrepancy in diagnosis, the changing of diagnosis is often of necessity in the diagnostic process; however, when there is the lack of appropriate explanation and due consideration given to the patient, this inevitably leads to anxiety. The fault may be partly due to the patient, when he changes his doctor at his own will. When more than one doctor is involved, the problem becomes complicated. It is often the case in iatrogenic disorder that the attending doctor refers his patient to a specialist without taking on the final responsibility of integrating the reports made and making them understandable to the patient. This is similar to the concept referred to as "collusion of anonymity" by Balint. s The negligence of considering the social and psychological problem underlying the cause and course of the disease is a serious one. Though the problem may have existed TABLE V. NEUROTIC TYPE AND IATROGENIC FACTOR
Disc",pancy in Dia1itnosis
Social & Psycrhob0IIOlle'micsal P
Purely Medical Problems
Anxiety
:'oIeurotic Type Hysteric Type Hypochondriac Type Phobic Type TOTAL
Problems related to doctor-pt. relat.
2
(I
I
11
0
.'I
U
4
8
0 U 3
3 I
2
5
26
0
10
9
135
PSYCHOSOMATICS
before his relation to the doctor, it does not indicate that the fault lies completely with the patient alone. It is the responsibility of the doctor to recognize this fact and hence take such into consideration in his approach. As is demonstrated in the case reports, the negligence in considering such problems aggravates and prolongs the course of the disease. The necessity of approaching the patient in a comprehensive manner and not merely on a physical level is especially emphasized. For the purely medical problem, it is revealed that in some instances, the fault lies completely on the doctor's part, such as in misdiagnosis. However, in cases where there is difficulty in determining the final diagnosis or the method of treatment, the anxiety of the patient is unavoidable to a certain extent. Nevertheless, hy no mcans should the uncertainty of the doctor be projected to the patient. It is the distrust in the doctor that leads the patient to anxiety. The exact diagnosis or method of treatment does not necessarily need to be told; however, the psychological needs must he recognized; support and reassurance based on these needs must be given. The problems relating directly to doctorpatient relationship were most prevalent in number. In considering the process by which the patient seeks medical help, it is supposed that the patient is motivated to come for relief of anxiety concerning his bodily condition. It is the relief of anxiety he is seeking, not necessarily the exact name of the diagnosis. If the doctor's response is one of a threatening or inappropriate nature, that is, disregarding the patient's emotional needs, the undesirable result is inevitable as is demonstrated in the case reports. The unnecessary use of medical terms often increases the patient's anxiety, because the meanings are not clear to him. It is difficult to find the solution to this problem and determine whether the fault lies in an act of omission or commission. The conscientious doctor's behavior or words expressed with good intention can also be misinterpreted at times, thus illustrating the difficulty in communication caused through the difference in feeling and interpretation of the two parties. It is clear that the doctor must recognize the difference of interpretation of 136
expression and avoid comments which may lead to misunderstanding and hence to the increase of anxiety. CASE REPORTS Ca.~e 1. Female, aged 34, a housewife. Mrs. K had experienced pregnancy kidney four times and was phobic towards pregnancy and delivery. She was admitted to a nearby hospital for her fifth delivery and was told that she had arrhythmia according to her electrocardiogram finding. She had complaints such as shortness of breath at that time. During a caesarean section, an error was made in blood typing in transfusion. She experienced a tightening feeling in her heart and since then, her anxiety increased with additional complaints such as dizziness and headache. She was hospitalized thrice in different hospitals in a year. At this time, she was diagnosed as having myocardial infarction, coronary insufficiency, myocardial damage, arterioselerosis, etc. Thus the discrepancy in diagnosis, the unm'cessary use of medical terms and misdiagnosis were committed. She was also told at one time, without an explanation, that she was too insistent in her anxiety concerning her condition; she was rderred to a psychiatrist. She was admitted to our hospital in a state of anxiety neurosis. Upon examination the electrocardiogram showed a slight deprcssion of the ST seJ.,'JUent and a flattening of the T wave. Upon exercise, these changes increased and thl' diagnosis was medically difficult to determine. With her emotional state in mind, which was diagnosed as anxiety neurosis with hypochondriac tendency, a tranquiliz{'r was administered and supportive therapy was given. During hospitalization, her fear concerning her heart lessened; however, because of her hypochondriac character, her object of fear changed and she became phobic of leukemia, cancer, etc. In spite of the supportive therapy given, her condition did not show much improvement.
Case 2. Male, aged 28. Script writer. Mr. N began to have gastric pain two years ago and upon fluoroscopic examination, had been told that "nothing was wrong." He came to our hospital in June 1964, because his symptoms had be{'Ome worse, and complained of loss of weight, nausea, vomiting and cramp in the stomach. During his visits to the out-patient department for three months, his symptoms did not improve and he was treated only with medication. He was dissatisfied with the fact that fluoroscopic examination was not done. He was admitted to our hospital in September of the same year. Upon his first fluoroscopy, he was told that there was "pyloric prolapse" and "suspected gastric ulcer." Upon second examination he was informed that "it was not ulcer, but an atrophic gastritis" in addition to the pyloric prolapse. He became extremely dissatisfied, because there was a discrepancy of diagnosis. His symptoms of nausea, hematemesis and cramp in the stomach continued. He persistently insisted that such symptoms could not be caused by a simple gastritis, and expressed obvious dissatisfaction at the fact that his condition was not due to an ulcer. He began to show hypersensitive reactions to the explanation given and to attitudes of Volume VII
IATROGENIC DISEASE-ISHIKAWA ET AL the doctors and nurses because of his extreme nervousness. Upon repeatt'd examination by gastro-camera and fibt'rscope, his diagnosis was concluded as gastritis. The patient did not trust the doctor and the doctor did not aCCl?pt the patient's emotional reaction but only told him that his condition was psychogenic. His distmst towards the doctor increased and his symptoms continued aftt'r discharge from the hospital. This caSl' had definite hypochondriac tendencies as observed from his Iwhavior during hospitalization. However, in addition to this factor, the approach taken by the doctor was inappropriate and aggravated his condition. He only approached the patient on a physical level, and though he explained that the rondition was psychogenic, he did not take any action towards psychotherapy.
Case 3. \1311', ag..d 30. Um·mploycd. \Ir. I had stlfTered insomnia since the agIo of 16. HI' is an introvert in character, prefers Iit<'rature and tt'nds to be serious in thought. Eight years ago, he sought medical help because he was in an emotionally ('xhausted state with eomplaints of insomnia, discomfort in the chest, anorexia, g('lll'ral malaise, etc. HI' was concerned over his future and of life at that time. Upon examination he overhmrd the doctor explaining to th,' medical students that he would ('wntually suffer from a grave heart attack. Since 11l' heard till' threatening statement, 11(' became phobic towards heart disease and visited sewral doctors within a two we('ks' period. He was told by these doctors such statements as "nothing wrong", "beri-b('ri", "arrhythmia." \Vith the discr('pancy in diagnosis, his anxiety had reached its Ill'ight. He resigned from his work, could not leave hom(' and gave up the thought of marriage. For as long as eight years he visitt·d different doctors without being given any definite reassurance concerning his condition. He came to our hospital in January 1963, for an electrocardiogram. The findings were flat T in I('ads I, Hand V._.; after exercise a slight depression in the ST segment (junctional type) was found. In this patient, the reaction was of the phobic type. It was caused by the doctor's words suggesting a serious heart attack. His character and personality obviously contributed to the development of neurosis. The significance of the fact that none of the doctors gave him support on a psychological level cannot be denied. In our hospital, the electrocardiogram was carefully discussed by several doctors. Considering the fact that he had practically led a fruitless life for eight years and with his personality traits in mind, we gave him rt'assurance and support that he could live a normal life. Continued observation and psychological support is being given.
In considering the above factors in the development of iatrogenic disease, it is believed that the crux of the problem lies in the fact that there is a basic difference in the integrating process which takes place in the patient and in the doctor, in arriving at a certain interpretation. The patient's perception, interpretation and offer of information to the doctor is introceptive in nature; May-June, 1966
on the contrary, the doctor's response to the information offered is based on extroceptive factors. 9 The dual meaning of disease as perceived by the patient (autogenous illness) and the disease as perceived by the doctor (iatrogenous illness) is discussed by BalinPll and offers the challenging problem of "matching" the two illnesses. It is the gap between the two that constitutes the nature of the problem which exists in the causation and aggravation of iatrogenic disease. Only through the recognition of this gap and the matching of the two, can the prohlem of iatrogenic disease he coped with. It was emphatically suggested throughout this study, that attentive listening to the patient and an approach on the psychological level is the beginning of recognizing and preventing the occurrence of iatrogenic disease. Only through proper recognition of the patient's need for an appropriate response, can the responsibility of the physician he fulfilled. Basic prohlems such as inadequate medical education of the doctor to approach the patient from a psychosomatic point of view and also the inadequacy of the system of medical practice itself in reducing the gap hetween the two are serious ones which we must endeavor to improve. SUMJ\IARY
In an attempt to clarify the genesis of iatrogenic disease, a study was made on 50 cases who presented iatrogenic problems. The analysis was made through following the process of communication between the patient and the doctor in general medical practice. As a result, the problems found were grouped under four major areas. 1. Problems created through a discrepancy in diagnosis. 2. Negligence of social and psychological problems. 3. Purely medical problems related to diagnosis and treatment. 4. Problems caused directly through inappropriate doctor-patient relationship. The predisposition of the patient and his social environment played an important role in the development of the disease. The neurotic types observed in our study were: (1) Hypochondriac type (2) Anxiety 137
PSYCHOSOMATICS
neurotic type (3) Phobic type (4) Hysteric type. The hypochondriac type was most prevalent in number. No depressive reactions were found in our study. The causative factors were not simple, but multi-causative, in which one played upon the other in the development of the disease. Three case reports were presented to demonstrate this phenomenon. The chief mechanism by which iatrogenic disease developed was found to be the difference in the process hy which the patient and the doctor perceive, integrate and interpret the disease and the lack of proper communication between the two. ACK:"OWLEOC:-'IE:"T
The authors wish to thank Professor Kobayashi, Director of the Department of Internal Medicine for his arrangement and advice in carryin~ out this study and to the members of the department for their collaboration. We are also indebted to Professor Ikemi of the Kyushu University for his guidance and advice in carrying out this study.
REFERENCES
1. Dorland, W. A. N.: The American Illustrated Medical Didicmary. Philadelphia: W. B. Saunders, 1954. 2. Iatrogenic Disease (Discussion on disease caused through medical practice) Shindan to Chiryo. Diagnosis and Treatment, 49:945, 1961. 3. Hino, S. et al.: Special edition on Iatrogenic Disease. Sogo Igaku, Medicine, 21 :4, 1964. 4. Wheeler, E. D., Williamson, C. R. and Cohen, M. E.: Heart Scare, Heart Surveys, and Iatrogenic Heart Disease. lAMA, 167:1096, 1958. 5. Hart, A. D.: Iatrogenics and Cardiac Neurosis. lAMA, 156:1133, 1954. 6. Kanehisa, T. and Okubo, N.: Iatrogenic Neurosis. I. Japanese PSljchosomatic Societlj, 3:36, 1963. 7. Mayer-Gross, W., Stater, E. and Roth, M.: General. PSljchiatrlj. London: Cassell, 1955. 8. Balint, M.: The Doctor, His Patient and the Illness. London: Pitman, 1964. 9. Stenback, A.: Physical Health and Physical Disease as Objective Fact and Subjective Experience. Arch. Gen. PSljchiat., 11 :290, 1964. 10. Balint, M. and Balint, E.: PSljc1lQtllerapeutic Techniques in Medicine. London: Tavistock, 1961.
Truth lies not in facts, hut in the relation between facts. Collected facts do not constitute knowledge. Some physicians know so much they are suffocated heneath a dead weight of erudition. The difficulty lies not so much in the new ideas, which are readily accepted, but in escaping from the old ones. The Science and Art of medicine are not mutually antagonistic, and in many ways the art of medicine lies in knowing when and how to apply the science of medicine at the bedside, a task of ever increasing difficulty. But it is well to remember that science is no substitute for wisdom. - Preface - Pathology for the Physician, by WM. BoYD, M.D., Seventh Edition, Philadelphia: Lea and Febiger, 1965.
138
Volume VII
MAY-JUNE,1966
rsyc BIOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Iatrogenic Disease in General Medicine H. ISIIIKAWA, H. OHTSUKA and M. AOKI
• A study was attempted to clarify the nature of iatrogenic disease as ohserved in the practice of general medicine. The adjective "iatrogenic" stems from the word (iatros- - physician and genes - caused by) and was originally used hy Sir Arthur Hurst. It is a "term applied to disorders induced in the patient hy autosuggestion hased on the physician's examination, manner or discussion".' However, in recent years, the term "Iatrogenic Disease" has extended its meaning to include illnesses caused or aggravated through medical treatment, mainly drugs, and also those which are caused by suggestions made through mass media. In this study, the term was limited to its original meaning and to neurotic and psychosomatic reactions caused by the physician's words or hehavior. Interpretations concerning the definition of iatrogenic disease have been discussed hy many.~·" At the Sixth ConVl'ntion of the Japanese Society of Psychosomatic Medicine ( 1965), the definition was limited to tIl(' original in the symposium on "Iatrogenic Diseases." In conclusion, Dr. lkcmi (chairman) suggested the necessity of defining its term to the original to avoid ohscurity in its use. He also pointed to the fact that the physician's words or behavior often act as a "trigger" in the development of the disorder to the patient who is already in a prepared state to react. From the Fourth Department of Internal Medicine. Faculty of ~Iedicine, The UnivNsity of Tokyo and the Health Counselling Unit of the Tokyo University Branch Hospital, Tokyo, Japan. May-June, 1966
Studies concerning the mechanism hy which the disease develops, such as that of "'heeler' and Hart,'-' have suggested that the prohlem not only lies in the physician alone hut also on other factors. Kanehisa'; has reported on "iatrogenic neurosis" and the role of the physician in the social interaction with the patient. In considering the complexity of the mechanism by which the illness is caused or aggravated, it was postulated that there must be multi-causative factors in its occurence and not a simple "cause and result" relationship. From the ahove postulation that the genesis of iatrogenic disease is not caused hy a single factor, we have attempted to analyze the process in medical practice hy following the patient through from tIl(' time he perceives his unusual hody feeling to the point where the doctor reaches his diagnosis. In other words, to follow through the process of transfer of information between the two parties and to find the flaw in medical practice itself. (Fig. 1.) A general hody feeling exists in all persons. The normal individual too is suhject at all times to somatic sensations slightly helow the level required to claim the attention of consciousness.; These sensations, pass unheeded and usually do not form the suhject of complaint. However, when there is a moment in which the attention of the person is drawn to the condition of the hody, these sensations secure conscious appreciation and are felt to be the sign or symptom of dysfunction or abnormality of the body. The process
II \I11111111\1Il1l11111111ll1l11111111111111~
131
PSYCHOSO\IATICS
Process of Communication in Medical Practice
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-
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I
Perceplion
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I
-
-
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,
-
-
-
-
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penono Ily. ml I leu
P'ycho,omol'C '.oct,on )
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-
-
-
-
specific diwOM
I
I
I
Interpretation
I
(general body feeling) ~
ICommunicoted Facts
I
.,C )
j
report)
t---
( (by man communocol;on \ (by physician. family
Pf,
response)
, Observolion
.....
II
II
Dr· PI Relolionship
1\
)
Or',
Inlegrolion
I
)1
, Interpretation
I
/ medicol diagnosi,)
(physicol ••ominotion) OnQtomicol
physiologicol
behavioral
II
Communicated facll
I Fil.:.
by which this perception hecomes apparent differs in every individual. The cause may he organic or functional. In interpreting this specific body feeling, the person's thinking process is founded on previous communicated facts which formulate the individual's medical knowledge. It may he through mass media, physician, family and other sources. Besides these, there is the basic character of the person, personality traits and milieu which influence its interpretation. \Vith these influencing factors, the patient integrates his thinking and comes to the doctor with his complaints. The doctor on the other hand, in accordance with the patient's report, makes his observation based on knowledge derived from medical science. Through examination and contact with the patient, his thoughts are integrated and a final interpretation is reached, which is usually the medical diagnosis. In communicating this interpretation to the patient, he is informed as being healthy or as having a specific disease. However, in certain individuals, because 132
of the difference in the integrating process, the understanding of the bodily condition may he of different nature and thus form a circuit hy which the information or suggestion given by the doctor becomes a stimulus and acts upon the perception of the patient producing a neurotic or psychosomatic reaction. The physician often does not realize the fact that diagnosis is not a one way process. He needs to recognize the fact that the process of diagnosis is a two way process in which the patient also participates and acts upon his own interpretation and arrives at a self-diagnosis. The recognition of this process is important. :I,IATEIUAL AlXD METHOD
The study was retrospective in design. The subjects were 50 in total: 30 hospitalized patients, 11 out-patients from the department of internal medicine and nine patients from the health counseling unit of the Tokyo University Branch Hospital. There were 21 males and 29 females. The range of age was from 20 to 60. The main disorders were: 14 cardioVolume VII
IATROGENIC DISEASE-ISHIKAWA ET AL
(Fig. 2) indicates the process in which the problem developed in general practice. 1. Problems created through the discrepancy in diagnosis. The problem arose when there was discrepancy of diagnosis made hy different physicians or by a single physician. The former was caused by the patient changing physicians at his own will, or by the attending physician referring his patient to another physician without taking on the final responsibility. In other words, it was the negligence of the attending physician to integrate and explain the results of the referrals that gave rise to unnecessary anxiety in the patient. The problem was also caused by one physician, when he carelessly changed the diagnosis without giving due consideration to the patient's feelings.
vascular, eight gastrointestinal, four neurological, one respiratory and three others. Twenty were completely free of organic disease. The analysis of the iatrogenicity was made through medical recordings of each patient and through interview. The criteria in determining the psychic manifestation were formed hy the psychiatrist and by us. RESULTS
As a result of the analysis made on the 50 patients, the iatrogenic factors were grouped under four major problems. 1. Prohlems created through the discrepancy in diagnosis. 2. i\'egligence of social and psychological prohlems. 3. Purely medical problems related to diagnosis and treatment. 4. Prohlems caused directly through inappropriate doctor-patient relationship. The four major problems were revealed through analysis in accordance to the aforementioned schema. The following schema
2. Negligence of social and pstjcllOlo{!,ical problemy. In some cases the social and psychological problems ohviously underlied the cause of the disorder. This factor was most prominent in patients of the hysteric type where the physician neglected to ohserve
Developmental Mechanism in Iatrogenic Disease
~-~-------~.~
I.
Comm
F"ll~
~Dr.
_
Pt. Relationship
D,!.creponc y In diognOSIS By one Dr P, changing Dr Dr refertng PI
InonprOP'Iole statement marle
With ground,
Threatening stotement
Not I"formlng known d,ognOSls AChve neglIgence
0' pollen' s psychn10gy
'napproprlate treol men'
ObMfvo,ion Ne-glllilence of 10<:101 &
pSychologicol problem
MedlCol
Sc.-nc.
M,tdtOgncK1J
OtOQn(Kt, d,Ht
10
de,.,""M Obleeln,"
It'
',eor. w'
~"' d.ff-euh to
Fi~.
May-Junt', 1966
:2
133
PSYCHOSOMATICS TABLE J. I.
.)
:1.
A:-IALYSIS OF MAJOR IATROGENIC FACTORS
Problems created throu~h tht> discrt'pancy in dia~nosjs Discr('pancy made by one doctor.... Discrepancy made by more than one doctor... The paticnt ('han~in~ doctors at his own will...... 1rrc.'sl)Qnsible n·r('rrin~ to another doctor.... ~e~li.liten('(' nf !'locial and psycholo.'{ical problems.. _ Pu...·ly medical problems relaled to dia~nosis and Ireal-
I 6 2 4 3
lIu'nt
:\'Iisdia.litllosis
_...............................
0
Difficuhy in dt'tt·rminin.'C dia.litnosis.... Difficulty in clt·t('mlinin.lit mt'thod of treatment... -t. Prohlrms caus('d directly throu.lith inappropriate doctorpatient rrlationship Statt'ment mad(' to avoid takinli{ responsibility.................... Iliappropriah' statement madt· en'n wh('n ba.~ed on SOffit' _~r()unds
Indifft'f('nt statC'ml'nt made- without definite ~rounds.... l'nll('c('ssary usr or medical technical terms.. statemC'nL................. . NOl informinl{ known dia~nosis.............................. ACli,'c 1H'~li!l:('nc(' or patient's psycholo~·.... Inal>prolniale. t~('almenL...... . MedIcal CUTloslty................
Thn'atenin~
5
n 4
6 6 :\ 5 0
40 0
them on a psychological level and hence aggravated the course of the disease.
3. Purely medical problems related to diagnosis and treatment. This factor consisted purely of medical problems, such as difficulty in determining diagnosis or therapeutic plan. Because of the lack of explanation and psychological consideration in these cases, unnecessary fear and anxiety were exaggerated and influenced the course of the disease. 4. Problems caused directly through inappropriate doctor-patient relationship. The problems were created directly by words or behavior of the doctor. This consisted of threatening statements, use of unnecessary medical terms, irresponsible statement without grounds or inappropriate explanation even when based on some grounds, etc. The incidence of iatrogenic factors found in the .50 cases are listed in Table I. As indicated in the table. one or more iatrogenic factors overlapped in the majority of patients and in some there were many factors involved. In cases with organic changes, the mechanism by which the iatrogenicity developed was more complex.
feelings. It was not totally the fault of the doctor's response alone, but the patient's basic character and personality that influenced the development of the disease. It was found that environmental factors also play an important role. In cases with environmental difficulties, the patient either consciously or subconsciously desired to escape from his environment. The doctor's inappropriate words and behavior were utilized to rationalize his wish to avoid his difficulties, thus inducing an apparent secondary gain. Though the main cause may lie on the patient's part, it was also a failure on the doctor's part because he was unaware of such psychological mechanism and to have concentrated on examination at the physical level alone. Eighteen cases were found to have environmental problems greatly influencing the cause and course of the disease.
2. Neurotic types. In addition to the above factors, the type of reaction to the iatrogenic factors were studied and analyzed. As a result, the neurotic reactions were classified into four types (Table II). It was found that the hypochondriac type was most prevalent followed by the anxiety neurotic type and hysteric type. The phobic type was few in number and no depressive reaction was found among our cases. TABLE II.
~eurotic
Anxi('tv N('urotic Type
Hysteric TYI)e Hypochondriac Tvpe Phobic Type
Anxietv :\eurosis Anxiety Neurotic tendency Conyersion Hvsteria Hysteric character Hysteric tendency :"ervous Hypochondriasis Hypochondriac t('ndencv Phobia Phobic tendency TOTAL -
Cases with environmental problems
Ii
7
4 6
8
9
i
2
1.1
I
2 50
18
----------.
FACTORS
1. Personality and environmental factors. Among the 50 cases, 31 were found to have definite personality problems which contribute<1 to the development of the disease. Because of their neurotic tendency. they were hypersensitive in reacting to the doctor's words or behavior and also to their body 134
:"0. or cases
T"pe
-_._----
11'TER-RELATIONSHIP OF CAUSATIVE
:-IEVROTIC TYPES
- - - - - _ - - -~-= ==-=--c===
The relationship between the physical finding and neurotic type revealed that the hypochondriac type had the least organic findings among the 50 cases. As shown in Table III a number of our cases had definite or slight organic changes which increased the complexity of the mechanism by which the iatrogenic factors acted. Volume VII
IATROGENIC DISEASE-ISHIKAWA ET AL TABLE III. PHYSICAL FINDINGS AND NEUROTIC TYPE Anxie.ty
Neurotic Type
HY'teric Type
Hypochondriac Type
4
12
20
4
5
15
Phobic Type
TOTAl,
OrJitanic
chanlle (-) Or~anic chan~e
.1
(±)
Orjitanic chan.~e
5
4
5
TOTAL
13
12
22
(+)
TABLE IV.
15 50
3
DISEASE SYMPTOMS A:>:D NEUROTIC TYPE Circulatory
CastrointesRespi· tina) Nervous ratory
system system system system Others TOTAL Anxiety neurotic
Type Hypochondriac Type HY'teric Type Phobic Type TOTAL
- - _ ...
12
n
0
n
13
8
<)
I
I
22
I
4
6
n
3 1
1 22
I
1
14
<)
0 1
0 4
3 50
--------_.
12
- - - - -
The neurotic types were also studied in relation to the disease symptoms (Table IV), A circulatory condition was related to most of the anxiety neurotic type; manifestations in the nervous system were seen mostly in the hysteric type. These findings seem reasonable from the standpoint of characteristics in the symptoms of these conditions. Other disease symptoms were also observed. In analyzing the iatrogenic factors in relation to the neurotic type, it was revealed that the problem of doctor-patient relationship was most prominent in the anxiety neurotic type in comparison with the others. This problem was also prominent in the hypochondriac type and in addition, the problem of discrepancy in diagnosis was important in this type. In the hysteric type, in addition to the problem of doctor-patient relationship, social and psychological problems were eminent. It was interesting to note the characteristics in the relationship of neurotic types to somatic conditions and to the iatrogenic factors (Table V). The following case reports are presented to demonstrate the inter-relationship of causative factors. DISCUSSION
The iatrogenic factors were revealed through analysis of the process of communicaMay-June, 1966
tion in medical practice as described in our first schema. (Fig. 1) It was found that the problem of iatrogenicity is not caused by a single factor but is developed through multicausative factors. The patient seeks the help of the doctor because he becomes concerned with his unusual body feeling. His motivation for coming to the doctor is based on an ambivalent feeling of anxiety and expectation. He comes to find relief from his anxiety. The state of preparedness on the patient's part cannot be underevaluated. His predisposition, personality traits, environment and somatic condition greatly influence the development and course of the iatrogenic condition. The "trigger mechanism" caused by the doctor's words or behavior often precipitates the development of the condition. As revealed in the results of the study, the iatrogenic factors were found in the four major areas. In the problem of discrepancy in diagnosis, the changing of diagnosis is often of necessity in the diagnostic process; however, when there is the lack of appropriate explanation and due consideration given to the patient, this inevitably leads to anxiety. The fault may be partly due to the patient, when he changes his doctor at his own will. When more than one doctor is involved, the problem becomes complicated. It is often the case in iatrogenic disorder that the attending doctor refers his patient to a specialist without taking on the final responsibility of integrating the reports made and making them understandable to the patient. This is similar to the concept referred to as "collusion of anonymity" by Balint. s The negligence of considering the social and psychological problem underlying the cause and course of the disease is a serious one. Though the problem may have existed TABLE V. NEUROTIC TYPE AND IATROGENIC FACTOR
Disc",pancy in Dia1itnosis
Social & Psycrhob0IIOlle'micsal P
Purely Medical Problems
Anxiety
:'oIeurotic Type Hysteric Type Hypochondriac Type Phobic Type TOTAL
Problems related to doctor-pt. relat.
2
(I
I
11
0
.'I
U
4
8
0 U 3
3 I
2
5
26
0
10
9
135
PSYCHOSOMATICS
before his relation to the doctor, it does not indicate that the fault lies completely with the patient alone. It is the responsibility of the doctor to recognize this fact and hence take such into consideration in his approach. As is demonstrated in the case reports, the negligence in considering such problems aggravates and prolongs the course of the disease. The necessity of approaching the patient in a comprehensive manner and not merely on a physical level is especially emphasized. For the purely medical problem, it is revealed that in some instances, the fault lies completely on the doctor's part, such as in misdiagnosis. However, in cases where there is difficulty in determining the final diagnosis or the method of treatment, the anxiety of the patient is unavoidable to a certain extent. Nevertheless, hy no mcans should the uncertainty of the doctor be projected to the patient. It is the distrust in the doctor that leads the patient to anxiety. The exact diagnosis or method of treatment does not necessarily need to be told; however, the psychological needs must he recognized; support and reassurance based on these needs must be given. The problems relating directly to doctorpatient relationship were most prevalent in number. In considering the process by which the patient seeks medical help, it is supposed that the patient is motivated to come for relief of anxiety concerning his bodily condition. It is the relief of anxiety he is seeking, not necessarily the exact name of the diagnosis. If the doctor's response is one of a threatening or inappropriate nature, that is, disregarding the patient's emotional needs, the undesirable result is inevitable as is demonstrated in the case reports. The unnecessary use of medical terms often increases the patient's anxiety, because the meanings are not clear to him. It is difficult to find the solution to this problem and determine whether the fault lies in an act of omission or commission. The conscientious doctor's behavior or words expressed with good intention can also be misinterpreted at times, thus illustrating the difficulty in communication caused through the difference in feeling and interpretation of the two parties. It is clear that the doctor must recognize the difference of interpretation of 136
expression and avoid comments which may lead to misunderstanding and hence to the increase of anxiety. CASE REPORTS Ca.~e 1. Female, aged 34, a housewife. Mrs. K had experienced pregnancy kidney four times and was phobic towards pregnancy and delivery. She was admitted to a nearby hospital for her fifth delivery and was told that she had arrhythmia according to her electrocardiogram finding. She had complaints such as shortness of breath at that time. During a caesarean section, an error was made in blood typing in transfusion. She experienced a tightening feeling in her heart and since then, her anxiety increased with additional complaints such as dizziness and headache. She was hospitalized thrice in different hospitals in a year. At this time, she was diagnosed as having myocardial infarction, coronary insufficiency, myocardial damage, arterioselerosis, etc. Thus the discrepancy in diagnosis, the unm'cessary use of medical terms and misdiagnosis were committed. She was also told at one time, without an explanation, that she was too insistent in her anxiety concerning her condition; she was rderred to a psychiatrist. She was admitted to our hospital in a state of anxiety neurosis. Upon examination the electrocardiogram showed a slight deprcssion of the ST seJ.,'JUent and a flattening of the T wave. Upon exercise, these changes increased and thl' diagnosis was medically difficult to determine. With her emotional state in mind, which was diagnosed as anxiety neurosis with hypochondriac tendency, a tranquiliz{'r was administered and supportive therapy was given. During hospitalization, her fear concerning her heart lessened; however, because of her hypochondriac character, her object of fear changed and she became phobic of leukemia, cancer, etc. In spite of the supportive therapy given, her condition did not show much improvement.
Case 2. Male, aged 28. Script writer. Mr. N began to have gastric pain two years ago and upon fluoroscopic examination, had been told that "nothing was wrong." He came to our hospital in June 1964, because his symptoms had be{'Ome worse, and complained of loss of weight, nausea, vomiting and cramp in the stomach. During his visits to the out-patient department for three months, his symptoms did not improve and he was treated only with medication. He was dissatisfied with the fact that fluoroscopic examination was not done. He was admitted to our hospital in September of the same year. Upon his first fluoroscopy, he was told that there was "pyloric prolapse" and "suspected gastric ulcer." Upon second examination he was informed that "it was not ulcer, but an atrophic gastritis" in addition to the pyloric prolapse. He became extremely dissatisfied, because there was a discrepancy of diagnosis. His symptoms of nausea, hematemesis and cramp in the stomach continued. He persistently insisted that such symptoms could not be caused by a simple gastritis, and expressed obvious dissatisfaction at the fact that his condition was not due to an ulcer. He began to show hypersensitive reactions to the explanation given and to attitudes of Volume VII
IATROGENIC DISEASE-ISHIKAWA ET AL the doctors and nurses because of his extreme nervousness. Upon repeatt'd examination by gastro-camera and fibt'rscope, his diagnosis was concluded as gastritis. The patient did not trust the doctor and the doctor did not aCCl?pt the patient's emotional reaction but only told him that his condition was psychogenic. His distmst towards the doctor increased and his symptoms continued aftt'r discharge from the hospital. This caSl' had definite hypochondriac tendencies as observed from his Iwhavior during hospitalization. However, in addition to this factor, the approach taken by the doctor was inappropriate and aggravated his condition. He only approached the patient on a physical level, and though he explained that the rondition was psychogenic, he did not take any action towards psychotherapy.
Case 3. \1311', ag..d 30. Um·mploycd. \Ir. I had stlfTered insomnia since the agIo of 16. HI' is an introvert in character, prefers Iit<'rature and tt'nds to be serious in thought. Eight years ago, he sought medical help because he was in an emotionally ('xhausted state with eomplaints of insomnia, discomfort in the chest, anorexia, g('lll'ral malaise, etc. HI' was concerned over his future and of life at that time. Upon examination he overhmrd the doctor explaining to th,' medical students that he would ('wntually suffer from a grave heart attack. Since 11l' heard till' threatening statement, 11(' became phobic towards heart disease and visited sewral doctors within a two we('ks' period. He was told by these doctors such statements as "nothing wrong", "beri-b('ri", "arrhythmia." \Vith the discr('pancy in diagnosis, his anxiety had reached its Ill'ight. He resigned from his work, could not leave hom(' and gave up the thought of marriage. For as long as eight years he visitt·d different doctors without being given any definite reassurance concerning his condition. He came to our hospital in January 1963, for an electrocardiogram. The findings were flat T in I('ads I, Hand V._.; after exercise a slight depression in the ST segment (junctional type) was found. In this patient, the reaction was of the phobic type. It was caused by the doctor's words suggesting a serious heart attack. His character and personality obviously contributed to the development of neurosis. The significance of the fact that none of the doctors gave him support on a psychological level cannot be denied. In our hospital, the electrocardiogram was carefully discussed by several doctors. Considering the fact that he had practically led a fruitless life for eight years and with his personality traits in mind, we gave him rt'assurance and support that he could live a normal life. Continued observation and psychological support is being given.
In considering the above factors in the development of iatrogenic disease, it is believed that the crux of the problem lies in the fact that there is a basic difference in the integrating process which takes place in the patient and in the doctor, in arriving at a certain interpretation. The patient's perception, interpretation and offer of information to the doctor is introceptive in nature; May-June, 1966
on the contrary, the doctor's response to the information offered is based on extroceptive factors. 9 The dual meaning of disease as perceived by the patient (autogenous illness) and the disease as perceived by the doctor (iatrogenous illness) is discussed by BalinPll and offers the challenging problem of "matching" the two illnesses. It is the gap between the two that constitutes the nature of the problem which exists in the causation and aggravation of iatrogenic disease. Only through the recognition of this gap and the matching of the two, can the prohlem of iatrogenic disease he coped with. It was emphatically suggested throughout this study, that attentive listening to the patient and an approach on the psychological level is the beginning of recognizing and preventing the occurrence of iatrogenic disease. Only through proper recognition of the patient's need for an appropriate response, can the responsibility of the physician he fulfilled. Basic prohlems such as inadequate medical education of the doctor to approach the patient from a psychosomatic point of view and also the inadequacy of the system of medical practice itself in reducing the gap hetween the two are serious ones which we must endeavor to improve. SUMJ\IARY
In an attempt to clarify the genesis of iatrogenic disease, a study was made on 50 cases who presented iatrogenic problems. The analysis was made through following the process of communication between the patient and the doctor in general medical practice. As a result, the problems found were grouped under four major areas. 1. Problems created through a discrepancy in diagnosis. 2. Negligence of social and psychological problems. 3. Purely medical problems related to diagnosis and treatment. 4. Problems caused directly through inappropriate doctor-patient relationship. The predisposition of the patient and his social environment played an important role in the development of the disease. The neurotic types observed in our study were: (1) Hypochondriac type (2) Anxiety 137
PSYCHOSOMATICS
neurotic type (3) Phobic type (4) Hysteric type. The hypochondriac type was most prevalent in number. No depressive reactions were found in our study. The causative factors were not simple, but multi-causative, in which one played upon the other in the development of the disease. Three case reports were presented to demonstrate this phenomenon. The chief mechanism by which iatrogenic disease developed was found to be the difference in the process hy which the patient and the doctor perceive, integrate and interpret the disease and the lack of proper communication between the two. ACK:"OWLEOC:-'IE:"T
The authors wish to thank Professor Kobayashi, Director of the Department of Internal Medicine for his arrangement and advice in carryin~ out this study and to the members of the department for their collaboration. We are also indebted to Professor Ikemi of the Kyushu University for his guidance and advice in carrying out this study.
REFERENCES
1. Dorland, W. A. N.: The American Illustrated Medical Didicmary. Philadelphia: W. B. Saunders, 1954. 2. Iatrogenic Disease (Discussion on disease caused through medical practice) Shindan to Chiryo. Diagnosis and Treatment, 49:945, 1961. 3. Hino, S. et al.: Special edition on Iatrogenic Disease. Sogo Igaku, Medicine, 21 :4, 1964. 4. Wheeler, E. D., Williamson, C. R. and Cohen, M. E.: Heart Scare, Heart Surveys, and Iatrogenic Heart Disease. lAMA, 167:1096, 1958. 5. Hart, A. D.: Iatrogenics and Cardiac Neurosis. lAMA, 156:1133, 1954. 6. Kanehisa, T. and Okubo, N.: Iatrogenic Neurosis. I. Japanese PSljchosomatic Societlj, 3:36, 1963. 7. Mayer-Gross, W., Stater, E. and Roth, M.: General. PSljchiatrlj. London: Cassell, 1955. 8. Balint, M.: The Doctor, His Patient and the Illness. London: Pitman, 1964. 9. Stenback, A.: Physical Health and Physical Disease as Objective Fact and Subjective Experience. Arch. Gen. PSljchiat., 11 :290, 1964. 10. Balint, M. and Balint, E.: PSljc1lQtllerapeutic Techniques in Medicine. London: Tavistock, 1961.
Truth lies not in facts, hut in the relation between facts. Collected facts do not constitute knowledge. Some physicians know so much they are suffocated heneath a dead weight of erudition. The difficulty lies not so much in the new ideas, which are readily accepted, but in escaping from the old ones. The Science and Art of medicine are not mutually antagonistic, and in many ways the art of medicine lies in knowing when and how to apply the science of medicine at the bedside, a task of ever increasing difficulty. But it is well to remember that science is no substitute for wisdom. - Preface - Pathology for the Physician, by WM. BoYD, M.D., Seventh Edition, Philadelphia: Lea and Febiger, 1965.
138
Volume VII