Thursday, March 04, 2004

Deaths Go Unexamined and the Living Pay the Price from The New York Times.

Dr. Gregory Davis hunched over an autopsy table last Thursday morning and cut into the lifeless body of a 52-year-old man.

Days earlier, the man, who had no real health problems other than a smoking habit, had been found dead in his apartment, the victim of a heart attack, a coroner determined.

But Dr. Davis, a forensic pathologist at the University of Kentucky, opened him up and found something startling. The actual cause of death was bacterial meningitis, a severe infection that could have spread to others before the man died......

Autopsies were once routine, performed in more than half of hospital deaths and, in some parts of the country, in a majority of deaths that occurred elsewhere. But over the last few decades, the number of such procedures in the United States and several other countries has sharply dropped.

Hospitals, afraid of being sued over mistaken diagnoses, increasingly forgo autopsies, experts say. The advent of sophisticated imaging techniques like C.T. scans and M.R.I.'s have created an illusion among doctors that the procedure is unnecessary. Grieving relatives, too, are often unwilling to shoulder the cost or wait for autopsies to be completed.

The decline, researchers say, may be gradually eroding the quality of care. A growing number of missed or mistaken diagnoses are going unchecked, depriving doctors of a learning tool. And studies, including one published last week, find that autopsies uncover missed or incorrect diagnoses in up to 25 percent of hospital deaths.

The story goes on to describe the theory that the fall in autopsy rate has adversely affected the quality of care and allows mistakes to go undected:

Another factor, some experts said, is the risk of malpractice suits if a mistake or a missed diagnosis is exposed. In most wrongful-death cases against a hospital or physician, an autopsy is critical to establishing negligence, said Wayne Grant, a lawyer in Atlanta who has won many malpractice suits over 25 years.

"Of the potential death cases that we have turned down, well over 50 percent are cases in which there has not been an autopsy," Mr. Grant said. "When a patient dies and there's no autopsy, the doctor can bury his mistakes along with the patient."

My, My...well, moving along. DB has already ranted on this follow-up editorial:

Autopsies have dwindled for a number of reasons. Hospitals were once required to perform them to be accredited, but that requirement ended in 1971. Insurance companies do not pay for autopsies. But the problem really lies in our attitude toward them. In recent years, families have become increasingly reluctant to authorize autopsies, and doctors too often believe that modern diagnostic tools like CAT scans and M.R.I.'s have made them obsolete. Yet underlying these reasons is another, more pervasive one: the risk of malpractice suits. An autopsy that uncovers an error in treatment also uncovers the potential for litigation. Never mind that it may improve subsequent diagnoses.

An overwhelming amount of what we know about the human body and its diseases was discovered by means of autopsies. X-rays and M.R.I.'s may create the illusion that the human body is now, somehow, translucent, more open to the scientific eye, but the fact remains that in many ways, we are still as opaque as we ever were. Hospitals can discover how well they're doing not only by the number of people they cure, but also by closely examining a reasonable percentage of those they don't cure. To assume that a patient has died of a diagnosed disease is, too often, to assume too much.

I agree wholeheartedly with DB that this is over the top. I have only twice had a family member agree to an autopsy after an unexpected death. I have only been asked to order one once, and complied. The autopsy is a unique learning experience and one that medical students today rarely experience. When I did path my second year one of the requirements was to observe an autopsy. About 1/4 of the class had to view one simultaneously because of the low numbers. I took a autopsy elective my fourth year. They were so rare I was able to greatly improve my golf game. I think the real reason that autopsy rates have gone down is an economic one, the survivors don't want to pay for it.
But what of the growing industry of private autopsy services? According to this California entrepreneur business is booming:

Autopsy companies say they are benefiting from publicity about shocking cases of medical malpractice.

"We can almost time it," said Sebastian of Northwest Autopsies. "I'll see a story on the 7 a.m. news about the number of people being killed by hospitals, and our phones light up."
In one recent case in Los Angeles, an elderly woman felt strange after undergoing heart surgery. The woman died after ordering her daughter to have an autopsy done if she passed away.
A pathologist from 1-800-AUTOPSY found a piece of gauze left in the woman's heart. "I'm sure (the daughter) has a case, but she doesn't have her mother. Money isn't everything," said Herrera's wife and business partner, Vicki.

Even some university medical centers offer private autopsy services, including the University of Kentucky pathology services provided by Dr. Gregory Davis. The private autopsy services offered by Dr. Davis, which can be quite lucrative, somehow did not make it into the first story linked above. I wonder why?

Anyway all this pathology/autopsy stuff reminded me of a medical/science-fiction story I read when I was in grade school titled Star Surgeon. In this tale the intergalactic medical corps had red uniforms for internists, green ones for surgeons, and was run by the black-uniformed pathologists. Interesting concept to say the least.
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