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
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
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
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.
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