The revenge effect in medicine

TANTALUS, in Greek mythology, was made to stand in a pool of water beneath a fruit tree with low branches, but with the fruit ever eluding his grasp and the water always receding before he could drink.

Modern scientific medicine is confronting a litany of similar phenomena.

Antibiotics were designed to cure infections by killing bacteria or by stopping their proliferation and activity. However, antibiotic resistant bacteria have become more of a problem than some of the original infections. Interestingly, the more complex we design an antibiotic to be, the more difficult it is to conquer the bacteria that become resistant to it.

Prosthetic devices, implanted equipment, organ transplantation and the myriad of other newer therapeutic procedures have given birth to newer problems, which at times could be more complicated than the original disease itself.

Mass production of and improved access to pharmaceuticals have led to increased usage of medications for treatment of various diseases. Nevertheless, adverse reactions and medication interactions are becoming more prevalent with polypharmacy.

Automated alarms in monitors and other medical equipment helped us recognise problems quickly. But the ubiquitous and incessant beeps and dings, which have numbed our cochleae, have led to alarm fatigue. This is being recognised as a significant safety risk in some specialties, such as intensive care.

The list could go on. I am sure you will be able to add many more such examples. These phenomena, called revenge effects, have been well known for decades outside of medicine.

Washing machines actually increase the time it takes to wash clothes, automobiles have become slower than horse-drawn carriages because of traffic gridlock, call centres make contacting organisations more difficult, the ease of electronic communications is more or less nullified by the ever-increasing risk to privacy and security, and more time is spent on ground than in air when taking a flight, to name a few.

While the person who invented the term “revenge effect” may elude precise identification (not an unusual scenario for inventing something of significance), individuals ranging from philosophers, inventors, and writers to army generals were variably attributed with pointing out the inherent problem with technology, bureaucracy and anything new.

That is, the problem of things biting back and eventually defeating their own purposes. It is not to infer that those individuals were “change haters”, but to the contrary, they were champions of change themselves.

History set aside, the implications of revenge effect are nothing to be taken lightly. Revenge effect has significant negative consequences in health care, as it has in the society in general.

Revenge theorists postulate five general mechanisms of “bite back”. They are: recomplicating, repeating, regenerating, recongesting and rearranging (Tenner E. Princeton Alumni Weekly. October 22, 1991; pages 12-16). It appears possible that more than one mechanism could be at play in any given “bite back” situation.

Take for instance the ingenious invention of patient controlled analgesia (PCA) – a simple invention whereby the patient can deliver a pain medication as and when needed with the press of a button. While the initial design was patient controlled, the addition of a complexity in the form of a “background infusion” (which is not patient controlled) is known to cause inadvertent overdosing problems.

Because of perceived and actual safety issues, the amount of nursing workload to monitor and document the PCA could increase to a level where we will ask ourselves the question, “is it easier and safer for the nurse to deliver the medication instead of the patient themselves?” – thereby defeating the very purpose of the invention.

The predominant problem of PCA is one of recomplicating – adding more features to what is a simple device could eventually violate its intended purpose.

The problem with medication interactions and adverse reactions is one of repeating – because it is easy to repeat the process (ie, prescribe, procure and administer), more patients are on more medications and the “bite back” happens.

Regenerating is a revenge mechanism that happens when the solution to a problem (antibiotic for infection) revives or amplifies the problem (infection by resistant bacteria). A problem very similar to that which arises due to increased usage of nondegradable materials – such as disposable plastic medical equipment – which could themselves become pieces of garbage with negative environmental consequences.

While computerised health information systems have made entering and accessing clinical information easier, they eventually could become slower as the amount of information entered and accessed increases. This is revenge effect using the mechanism of recongesting – an initially faster system becomes eventually slower because of more people using it. Gridlock happens on roads for the same reason.

An interesting mechanism of revenge, namely rearranging, happens when the burden is transferred from one entity to another under the guise of a solution to a problem. To give an example, when air conditioning is provided to a train compartment in a subway, the heat exchanged is borne by the people standing in the platform of the station. Cigarette smokers, for instance, could experience a disproportionately high disease burden, but the cost and high resource utility for their treatment could potentially burden the general public (especially in some countries with universal or near-universal health care).

Can we prevent the revenge effect altogether? Probably not. But we could certainly mitigate its effect by acknowledging its possibility.

Complexity appears to be a significant contributor to some mechanisms of revenge. While adopting change, we should be cautious about an unnecessary complexity being inconspicuously integrated into it. No one could have summarised more aptly the importance of simplicity than E F Schumacher writing in the Radical Humanist (1973; 37[5]: 22): “Any intelligent fool can make things bigger, more complex and more violent. It takes a touch of genius and a lot of courage to move in the opposite direction.”

Food for thought.

Dr Balaji Bikshandi is a specialist intensive care physician based in Canberra and an inventor attached to the Department of Industrial Design at the University of Canberra.

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