Autopsies the decline of medical knowledge

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Autopsies The Decline of Medical Knowledge


4 March 2001
Autopsies: The Decline of Medical Knowledge
In 1970, our next-door neighbour, Mr. McManus, died while shovelling his driveway. His wife was berated and raked with guilt because she did not hire a contractor to clean the driveway. For days, Mrs. McManus was in extreme grief because she believed that had she not insisted on the driveway being shovelled, her husband would still be alive today. When an autopsy1 was performed on Mr. McManus, it was revealed he had an advanced heart condition that could have caused his death at any time. Through the use of autopsies, Aids, and Legionnaire’s disease were discovered, and the ‘café coronary,’ which was found to be a choking death, could have been averted by the Heimlich manoeuvre. Although autopsies have made invaluable contributions to the field of medicine, autopsies performed in the United States today are at such lows that our medical knowledge is seriously impeded. Why have autopsies that were once the "Gold Standard’ of the medical profession, no longer being performed in the same numbers of the past? The answer to that question can be contributed to four factors: professional pressures, technological advances, social concerns and financial pressures.
First of all, Professional pressures have attributed to a drop in autopsy rates. Autopsy rates in our nations hospitals have been declining for over a decade. Next, autopsies taking two or more hours are viewed as unproductive when medical skills can be used in other areas. Pathologists2 today are dealing with increased workloads. Also, decisions of the county coroners /medical examiners3 in most states will determine on whether an autopsy is warranted.
Autopsies Autopsy rates in our nations hospitals have been declining for over a decade. According to Dr. Hanzlich Baker, approximately one half of the deaths in America were autopsied in the1950s, but today, autopsies are being performed on less than 11% of the deaths (Baker, H). Also, a 1994 survey of 244 hospitals, conducted by the College of American Pathologist, showed that almost half had autopsy rates at or below 8.5%, and 75% had rates below 13.5% (Baker, P; et al).
Next, autopsies taking two or more hours are viewed as unproductive when medical skills can be used in other areas. Autopsies usually take a minimum of two hours and are labour intensive. Dr. Alice Haghir, Chief of Pathology at Samaritan Medical Center, in Watertown, New York, remarked that autopsies are but a small part of the duties of pathologists. Pathologists perform all lab work, blood tests, biopsies and examination of removed tissues for diagnosis. Dr. Haghir agreed that in some hospitals, pathologists and hospital administrators view autopsies as being unproductive when living patients are waiting medical results, such as biopsies, especially when the possible cause of death is known (Brody; Haghir).
Pathologists today are dealing with increased workloads. There has almost been a 50% increase in workloads due to a decrease in physicians entering the field of pathology, and financial considerations stemming from the ‘managed care / HMO4’ system (Brody; Goldhahn). With the inception of the managed care/ HMO’s system ten years ago, Dr. Haghir explained, hospitals receive a prescribed amount of money per patient for a full year of health care, regardless if that patient needs expensive surgery or lengthy lab tests. Hospitals needing to cut costs would increase the pathologist’s workload or make cuts in the amount of pathologists on staff (Haghir).
Also, decisions of the county coroners/medical examiners in most states will result on whether an autopsy is warranted. When an out-of-hospital death occurs, either suddenly, unexpectedly, or as a result of unusual or violent circumstances, in most states, it is the decision of the county coroner or medical examiner to determine whether an autopsy is warranted, although some states, such as New York, mandate that autopsies be preformed in certain situations (Haghir).
Additionally, due to technological advances, autopsy rates continue to decline. With the advent of advanced diagnostic tools, autopsies are believed to be a quaint relic. Likewise, in many medical schools, there has been a decreased emphasis towards teaching the basic sciences due to the specialization of the medical fields.
With the advent of advanced diagnostic tools, autopsies are believed to be a quaint relic. The dramatic and rapid advancements in diagnostic tools, such as C.T. and P.E.T. scans, and M.R.I’s, have resulted in the perception among clinicians that the autopsy can be replaced by technology (Brody). With the advancements in computed tomograpy and magnetic resonance imaging cause doctors to falsely assume that nothing can be learned from an autopsy. "We will soon have the technology to completely view images of all the internal body functions, including cell formations," remarked Dr Haghir, "but no test can replace the accuracy of the autopsy."
Likewise, in many medical schools, there has been a decreased emphasis towards teaching the basic sciences due to the specialization of the medical fields. Clinical problem solving curricula have started to replace basic pathology. Dr. Haghir agreed, but added that ‘clinical problem solving’ was a medical euphemism for teaching using CD’s, the internet and teleconferencing. Many of our graduating medical students have had no autopsy procedural training, let alone received any schooling in autopsy request permission. The current thinking in some medical schools is that medical students pursuing specialized career fields need not fully learn pathology until later, if and when needed (Haghir). By the same token, many have not even viewed an autopsy in progress or the insides of a cadaver5 (Angrist,; College of American Pathologists Conference; College of American Pathologists Foundation; Williams).
Furthermore, financial pressures have prompted many hospitals to discourage or abandon autopsies all together. Doctors are told that fewer autopsies will mean more money for other uses. Unfortunately, the lack of reimbursement form managed care / HMOs’ has prompted some hospitals to charge for requested autopsies. Because of fear of malpractice and lawsuits, doctors are reluctant to request an autopsy.
Doctors are told that fewer autopsies will mean more money for other uses. Traditionally, hospitals have covered the cost of autopsies as an operating expense. Dr. Gregory Davis, a forensic pathologist at the University of Kentucky stated, "In a lot of modern hospitals, doctors are told indirectly that doing fewer autopsies means more money available for something else" (Brody). Dr. Haghir explained, "For example, if I am busy performing lab tests and such, the hospital will have to bring in another pathologist to perform the autopsy and the hospital will have to pay the pathologist around $2,000 or more per case."
Unfortunately, the lack of reimbursement from managed care/HMO’s has prompted some hospitals to charge for requested autopsies. Although Medicare doesn't require it, and most insurance companies do not cover the cost, the lack of reimbursement from managed care/HMO’s makes the autopsy a financial burden, which administrators and the pathology department must manage. These burdens have prompted some hospitals to charge families for requested autopsies, which might think twice, when told that the minimum costs can be $2,000 or more (Shute).
Because of fear of malpractice and lawsuits, doctors are reluctant to request an autopsy. Dr. Haghir commented that doctors are sometimes reluctant to request an autopsy for fear of malpractice claims and lawsuits for mistaken diagnoses. Dr. Davis questions his colleague's motives, due to the fact that 95% of good autopsy cases disputed any notions of malpractice (Brody).
Finally, the social concerns of society today have contributed to the deterioration in autopsy rates. As a result, misconceptions and myths by surviving family members have also led to a decline in autopsy rates.
Death of a loved one is a very sensitive issue for families to confront. An autopsy is sometimes viewed as a seemingly painful step in an already unpleasant process. Very often, families believe autopsies will delay transfer of their loved ones to the funeral home, or that the body will be "mutilated," preventing an open-casket funeral. Some families will object on religious grounds, though few faiths (Jewish and Islamic) actually prohibit an autopsy. Also, families are often unaware that they can request an autopsy (Geller).
Consequently, with our current autopsy rates sliding further into decline, it will be of no surprise that our medical knowledge of the future will also be seriously hindered. With the possible reality of deadly new diseases’ on the horizon, the decline of autopsies could very well be the cause of not finding a cure. For our neighbour Mrs. McManus, I can only say, that had not an autopsy been performed, she may never have known the cause of her husband’s death.
Works Cited
Angrist, A. "What Remedies for the Failing Autopsy?" Symposium on the Autopsy. Journal
of the American Medical Association. 1965: 193: 805-814. Archives of Internal
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Baker, Hanzlich, R. "Institutional Autopsy Rates." Archives of Internal Medicine. 1998;
158: 1171-1172. Archives of Internal Medicine.
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Baker, PB, Howanitz, PJ and Zarbo, RJ. "Quality Assurance of Autopsy Permit Form
Information, Timelines of performance and Issuance of Preliminary Report: a College of
American Pathologists Q-Probes Study of 5434 Autopsies from 452 Institutions. Archives
of Pathology Labatory Medicine. 1996; 120: 346-352.
1/24/01.
Brody, Jane,E. "A Price to Pay as Autopsies Lose Favor." The New York Times. Lexix-
Nexis Academic Universe. January 9, 2001 Section F; 8: Column 1; Health and Fitness.
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College of American Pathologists Conference XXIX. "Restructuring Autopsy Practice for
Health Care Reform. Archives of Pathology Labatory Medicine. 1996; 120:700-785.
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College of American Pathologists Foundation Conference on the Autopsy. "Revitalizing the
Ultimate Consultation. Archives of Pathology Labatory Medicine. 1984; 108:437-512.
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Geller, Stephan, A. "Authors try to Revive Interest in Autopsies." Medical Data
International. Lexis-Nexis Academic Universe. May 1, 2000.
1/24/01. http://www.weblexis-nexis.com/univers
Goldhahn, Richard, T. "Autopsy Rates and Diagnosis (Letter to the Editor)." The Journal of
the American Medical Association. 16 June 1999; v281: i123: 2181.
1/24/01. http://www.web2.infotrac.galegroup.com
Haghir, Alice. Personal Interview. 23 February 2001.
Shute, Nancy. "The Signature of Death." U.S. News and Report. August 7, 2000; v129: is:
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Williams, MJ, Perry, TM. "The Autopsy, a Beginning, Not an End." The American Journal
of Clinical Pathology. 1978; 69(supp12): 215-216.
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