The Evolution of the International Classification of Disease

The International Classification of Disease is perhaps one of the most important diagnostics documents in the medical world. It categorizes diseases and medical incidents that can be encountered, and the document reflects a broader context in which it is created. The ICD aids with health policy decision making and can with a process of finding treatment for those who are suffering. From October 12, 2016 to October 15, 2016, Japan hosted a conference focused on the 11th revision of the ICD, or ICD-11.

These discussions of revision have already begun soon after ICD-10, designed to begin use formally by 2016, was released on Oct. 1, 2015. ICD-10 is still being integrated throughout global health systems as they adjust from their use of ICD-9, which was first implemented in the US in 1979. With discussions beginning for the 11th edition of the ICD, it is important to look back at how the ICD has evolved over the past hundred years. More specifically, it is interesting to note how the ICD creators’ perceptions about medical practitioners have changed over time.

Being a healer is something that people in every society inherently admire. Without some sort of medical practitioner or spiritual guide to care for people’s health, no matter the era, humans would feel a sense of discomfort when they are in their weakest state. How people interact with their doctors is something that has evolved over time. Most notably, the expectation for doctors to acknowledge when a mistake has been made that caused a patient harm when that patient was under their care has changed. When comparing the ICD developed for use in 1910 to that developed for 2016, there are numerous differences that reflect shifts in the values held by the ICD creators. One such shift is that they now gives more weight to the idea that harm can be caused by those who intend to heal us than they did one hundred years ago.

In 1910, any mention of harm being caused from surgical complications is considerably infrequent. They are spread throughout the ICD and there is no direct mention of the term ‘complication’. For example, the 1910 ICD lists code 18 as Erysipelas: All forms of surgical or medical erysipelas regardless of location. Erysipelas was first identified as a disease in 1398, and has broadly been defined as: “a local febrile disease accompanied by diffused inflammation of the skin, producing a deep red color.” This is a disease that can arise from problems with sterilization in surgery and is a form of harm that can result from a physician’s negligence. While the definition in the 1910 ICD indicates that the erysipelas is an aftereffect of surgical or medical care, the ICD does not make any reference to ‘complications’ being the disease’s primary category. Instead, it is only under the broad category of General Diseases.

On the other hand, the 2016 ICD very directly addresses the concept of problems arising in medical procedures with the category of Complications of medical and surgical care (Y62-Y84), which includes numerous examples of problems that occur during operations while a patient under the care of medical professionals. The 2016 ICD has 22 categories (each with its own subcategories) that explicitly reflect procedural complications, while the 1910 ICD only implies that harm could have been caused by those conducting the procedure. It is evident that the 2016 ICD creators’ expectation of doctors is that they are fully aware of the impacts their actions have on patients. From this, it can be seen that society has become more bureaucratized. In 2016, there must be standards set by external agents such as lawyers and insurance companies that force physicians to acknowledge when a specific part of the healing process has gone awry. If those agents were not as influential, doctors would likely not have a need to decidedly state that complications arose because of actions performed during a procedure.

In the 1910 ICD, there is definitely limited acceptance of medical practitioners’ wrongdoing with only a few mentions of surgeries being a source of suffering. However, there is a significant focus on the idea that the patient’s actions could result in their medical complication. For instance, alcoholism was elaborated upon in many forms in the 1910 ICD: 56 Alcoholism (acute or chronic); 67 General paralysis of the insane includes a sub-cause of Alcoholic paralysis; 75-C includes Amblyopia from intoxication; 81 Diseases of the arteries, atheroma, aneurysm, etc. are diseases that alcoholism can exacerbate; and 113 Cirrhosis of the liver has Alcoholism as a sub-cause. The 1910 ICD notes only one categorical mistake that is attributable to the physician’s action, mentioning that the use of forceps caused the problem: in code 152 Other diseases peculiar to early infancy, the sub-cause “various consequences of labor (fracture of the cranium by forceps, etc.)” is noted. There is a high frequency of examples of patients causing their own problems in this ICD relative to the near nonexistence of doctors being the source of patients’ complications. This demonstrates that the creators of the ICD one hundred years ago was extremely focused on patients being responsible for their own suffering, while doctors’ pills-1173655_960_720procedures were rarely considered a source of that suffering.

The 2016 ICD remains focused on patients causing their own suffering. Alcoholism is substantially prevalent, even receiving its own category of F10 Alcohol related disorders under Mental and behavioral disorders due to psychoactive substance use, containing 48 sub-categories.[1] However, ‘complications’ that could be tied to medical practitioners’ actions became far more extensive in the 2016 ICD to the point that entirely new categorizations with this focus were created. For example, this is seen in Y65:

Y65 Other misadventures during surgical and medical care

Y65.0 Mismatched blood in transfusion

Y65.1 Wrong fluid used in infusion

Y65.2 Failure in suture or ligature during surgical operation

Y65.3 Endotracheal tube wrongly placed during anesthetic procedure

Y65.4 Failure to introduce or to remove other tube or instrument

Y65.5 Performance of wrong procedure (operation)

Y65.51 Performance of wrong procedure (operation) on correct patient

Y65.52 Performance of procedure (operation) on patient not scheduled for surgery

Y65.53 Performance of correct procedure (operation) on wrong side or body part

This is only one example of several sections within the 2016 ICD that show a change in how the ICD creators view medical professionals. More weight is given to the idea that they have the potential to make specific mistakes that negatively impact their patients. Those mistakes may be due to medical procedures becoming more complex with a greater potential for error in 2016. Even if the mistakes may not be directly attributable to the doctors, there is greater recognition that those mistakes occur while patients are under their care.

In the 1910 ICD, there are only several other codes including issues caused by procedures. These included: 109 Hernia, intestinal obstruction with the sub-causes of Kelotomy and Herniotomy; 110-B Other diseases of the intestine with the sub-causes of Enterotomy and Intestinal Resecton; 130-B Other diseases of the uterus with the sub-causes of Hysterectomy, Hysterotomy, and Metrotomy; 136 Other accidents of labor; 189-A Cause of death not specified or ill-defined with the sub-cause of Surgical Shock; and several mentions of problems caused by amputations. While it is stated that the surgery is the cause of something unfortunate happening to the patient, none of these categories refer to specific complications within the surgeries, and these procedural issues do not all fall under one unifying category.

As of 2016, the possibility for a procedure to be the source of a problem rather than just a solution is more apparent based on the explicit categorization of ‘complications’. For example, even more specifically than the broader Complications of medical and surgical care section is Y83: “Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.” The phrase ‘without mention’ remains non-judgmental of the medical practitioners’ inability to understand the reaction of the patient; however, using the term ‘misadventure’ is more unambiguous than simply listing the procedure name. There is a greater recognition that procedures have the potential to not go as planned. In 1910, the ICD creators only implied that harm could be caused by medical practitioners on occasion. By 2016, the creators of the ICD began expecting that nearly any problem a person has can be fixed by a doctor, and if that problem is not fixed, it is more likely that complications have arisen.

Between 1910 and 2016, the ICD was modified significantly. Recognizing how a categorization system has changed enables us to make broader conclusions about how the people who created the system have evolved. Comparing the two ICDs, it becomes clear that the 1910 ICD creators were not as concerned about doctors being the source of harm for a patient. Over the course of one hundred years, medical treatments have become more complex and high-tech, involving a greater number of personnel. That leaves the door open for more mistakes to be made and recognized. The medical community’s values and concerns shift over time, and it is clear that this shift can be tracked using sources of informational evidence like the ICD.

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