Zombie Semmelweiss wept.
And he got to have an autopsy: He died after two weeks [after being admitted to a mental institution and severely beaten], on August 13, 1865, aged 47, from a gangrenous wound, possibly caused by the beating. The autopsy revealed extensive internal injuries, the cause of death pyemia--blood poisoning.
I suspect part of reason for the drop in autopsies is paranoia about malpractice suits.
I bet it's more about cost-cutting and time-saving than paranoia about lawsuits.
I read something by Gawande himself about the decline in autopsy rates. I think maybe it's in Complications? IIRC, he attributes a lot of it to doctors being unwilling to broach the issue with the families of the dead. Interesting to see in the linked article the statistic that many families are willing but are never asked.
The reason my family said no to an autopsy when it was a possibility was that we were told it would cost $3000-$4000. At the time we did not know that the many thousands of dollars in end-of-life care was going to end up being covered by insurance, and there was no compelling family-history or cause-of-death reason to do the autopsy, so we just said no.
I've read an analysis arguing that we do too few autopsies in the States to be sure we don't have endemic vCJD. Can't find it now, though.
NPR did a several-episode series on the decline in autopsy rates a month or two ago, the only one of which I heard reported that it had a lot to do with declining budgets and the resultant godawful state of many coroners' departments. (Like, they're washing their hands in filthy sinks with a single bare overhead lightbulb.*) Oh, also something about coroners increasingly being elected officials who had little to no training in forensic medicine. That's likely quite relevant. Also something about an absurdly low percentage of autopsy test samples that ever actually came back from the testing bureau, this being a result of lack of funding as well, which sets up a downward spiral of diminishing returns in even bothering to conduct an autopsy in the first place.
Sorry to be so vague in my recall of the story; I came into it partway through, and only remembered it now.
* Yes, that sounds like melodramatic overstatement, but they did interview someone who described that.
Secondhand personal history has shown me that, yes, yes, with all the wonder diagnostic tools at their disposal, doctors still make a fsckload of errors, especially in cases with v. complicated histories.
Also that having new doctors in charge every couple of months is not helpful, but probably unavoidable in a teaching hospital.
I don't think 3 invalidates 2.
About a year ago they found some high readings in a full set of bloods that they'd taken from me because I was feeling (not seriously) ill. Earlier this week I went back to see the Professor of Infectious Diseases for the fifth time, and he told me, firstly, he still had no idea what was causing it and secondly, that he wanted to get to the bottom of it as much from personal pride (since I'm no longer feeling as ill) as anything else, so would I mind having them run some more tests.
No skin off my nose, it's free. But under the American medical regime there's no way I would be shelling out for essentially theoretical conversations with senior consultants every couple of months for ever. The only way they'd ever find out what I had would be if I died before the indicators went away and they did an autopsy.
The point being that not doing autopsies is a good way of perpetuating medical ignorance. In Britain they're legally required under a whole bunch of circumstances; maybe that would be a way round the 'fear of lawyers' thing.
In a UK context, Ben Goldacre's good on this soft of thing - the disproportionate appeal of the magic pill or technology over procedural or behavioural change with a far more reliable effect.
The other big problem in teaching hospitals is the "see one, do one, teach one" model of teaching which is one way of saying obliquely that hospitals don't generally believe in standardization of procedure, and the way that it still looks like a cottage industry.1
I used to read a blog by Paul Levy, the former CEO of Beth Israel Deaconess Hospital in Boston. He wrote with admiration about some of the ways that the Mayo Clinic has changed some of that model. See his post here on standardization in medicine:
When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.
I'm sure that people simulators would be as much like working on a real human as flying a simulated plane is to a real plane, but it's better than just watching someone do it once and having a go.
This looks to be a pretty relevant summary from someone in the field, "Autopsy Rate and Physician Attitudes Toward Autopsy" (with a fair number of references as well). Not a lot of data but apparently rates are declining in other countries as well. Concerns about malpractice are listed among others (including the potential over-reliance on diagnosis technology). This study (full text) from 2002, "The Role of the Autopsy in Medical Malpractice Cases, I:A Review of 99 Appeals Court Decisions" found no significant relationship but clearly the perception exists.
Even when a major discrepancy existed between the autopsy diagnosis and the clinical diagnosis, and the unrecognized condition was deemed treatable, defendant physicians were usually exonerated. Moreover, major diagnostic discrepancies were relatively uncommon in suits in which a physician was found to be negligent. Conversely, in about 20% of cases, autopsy findings were helpful to defendant physicians.
I posted this on the previous thread, but this one is more relevant: A new drug to help prevent premature births has just been approved. The new drug costs $1500 vs $20 for a non-proprietary equivalent, and the company making the drug is trying to shut down access to the alternative with threats of lawsuits.
I'm not really that much of a stabby person, but sometimes I'm sorely tempted to go all Knifecrime Island on these people.
I suspect part of reason for the drop in autopsies is paranoia about malpractice suits.
In addition to the reasons other people have given, I don't buy this because the time frame seems wrong. According to the article autopsy rates were already in a process of steady decline by the 70's. That seems earlier than you would expect if you thought it was being driven by concerns about malpractice.
It is depressing, however, to think that it's plausible that the medical profession as a whole is better off to never knowing what actually happened to somebody. I don't believe that is usually the case, but I can see why somebody who believed that would think that it was unacceptable.
The reason my family said no to an autopsy when it was a possibility was that we were told it would cost $3000-$4000.
Interesting. The article said that hospitals often end up footing the bill for autopsies (and that this was a reason why the numbers had declined). I can understand why they would want to bill the family, and I don't know how that gets determined, but the article also makes the case that the primary benefits are to the hospital, rather than to the patient so it would make sense for the hospital to pay for it.
Maybe ambulance chasing law firms could fund the autopsies on a no-malpractice-no-fee basis. Everybody wins!
14: That seems earlier than you would expect if you thought it was being driven by concerns about malpractice.
I recall malpractice as being a boogeyman back then. Supported here:
The second medical malpractice crisis [the 'first" was ~1840-1869 - JPS] occurred around 1970, when claims began to grow suddenly, causing the insurance carriers to dramatically raise their premiums to cover their expenses. At that time most of the carriers were multi-line commercial insurers, and many of them decided to drop out of the market when profitability declined.I think the data supports that James's formulation is correct.
I haven't read The Checklist Manifesto, but I'll bet a big part of checklist-resistance is performative desire on the part of doctors. Prescribing cutting-edge drugs or using the machine that goes 'ping' makes you feel like a superman and confirms your high status; checking off items on a clipboard doesn't.
but the article also makes the case that the primary benefits are to the hospital, rather than to the patient so it would make sense for the hospital to pay for it.
Even if the benefits are to the hospital, they're surely long-term and very hard to quantify (much as with health IT), so you need professional norms to keep the practice in place.
Professional norms or government intervention, that is.
17 seems true to me. Of all the students I've taught pre-meds are the ones with the largest gap between desire to been seen to excel and desire to actually understand the material. It was this experience that soured me on the medical profession. More than once I had to give a potentially career damaging grade to a student who had all the attributes I'd want in someone taking care of me when I was scared and in pain, merely because he or she didn't have the knack for problems of the sort never seen by doctors. Equally often I had to hand out top grades to people who could never be real healers, who would at most would be competent meat mechanics, and would no doubt pursue specializations chosen for prestige and remunerative potential. A couple of these latter verged on Randian sociopathy.
I haven't read The Checklist Manifesto, but I'll bet a big part of checklist-resistance is performative desire on the part of doctors.
He doesn't talk specifically about this, but that's definitely part of the story.
Brief review, since I do recommend the book:
I read The Checklist Manifesto in one sitting, and found it energizing in that specific way of reading a book that fundamentally agrees with one's vision of the universe. His basic premises -- such as the idea that it's more difficult than people think to be able to consistently do a moderately difficult task without error, match my sense of the world and relate directly to how I try to organize my own work.
If that's all the book said, it could easily have been a long article, but it ultimately tells three related stories from Gawande's personal experience, all of which I found interesting, and which I thought were usefully juxtaposed.
The first is of him becoming interested in this idea of checklists as a area of curiosity. It's something that he starts thinking about and noticing in the world, without having a plan of how he will make use of the idea.
The second involves him being invited by WHO to be on a committee that is supposed to come up with recommendations for a way to reduce the rates of surgical errors, worldwide. He has his doubts about the project, for a variety of reasons, but ends up getting involved and pitching his checklist idea.
The third story is of him convincing the other people of the group that the checklist is a good idea and trying to come up with something that could be used in hospitals around the world. In that section of the book he runs into the fact that it's very difficult to (a) write a useful checklist and (b) get it in use. I think he's honest about the fact that those are real difficulties, not just the result of people being closed-minded.
In that regard the quotation that I pulled is somewhat misleading. He does think that his surgical checklist should be adopted more widely, but he doesn't think that this will happen automatically just because it's a good idea. The book ends with him, essentially, starting to work on figuring out what it will take to promote the use of the checklist.
I think that last part is crucial to what makes the book interesting.
Here is Gawande's autopsy article:
http://www.newyorker.com/archive/2001/03/19/010319fa_gwnd_dept_fact
Professionals hate things like checklists. Checklists work but they lead to de-professionalization. This isn't always a bad thing for society in general but it is bad for the particular professionals.
A little poking around on the internet suggests that New Zealand has had a similar drop in autopsy rate (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC214120/) which seems to me to be pretty convincing evidence that malpractice suits are not the main issue. (New Zealand has long had government-run no-fault accident insurance.)
Professionals hate things like checklists. Checklists work but they lead to de-professionalization.
I'm not sure that's true if the stakes of failure are sufficiently high.
One of the examples that Gawande refers to frequently is the use of checklists in flying planes (and he has nothing but praise for the people at Boeing who write their checklists).
Here is Gawande's autopsy article:
Thanks. He says similar things.
So what accounts for its decline? It's not because families refuse--to judge from recent studies, they still grant that permission up to eighty per cent of the time. Doctors, once so eager to perform autopsies that they stole bodies, have simply stopped asking. Some people ascribe this to shady motives. It has been said that hospitals are trying to save money by avoiding autopsies, since insurers don't pay for them, or that doctors avoid them in order to cover up evidence of malpractice. And yet autopsies lost money and uncovered malpractice when they were popular, too.
Instead, I suspect, what discourages autopsies is medicine's twenty-first-century, tall-in-the-saddle confidence. When I failed to ask Mrs. Sykes whether we could autopsy her husband, it was not because of the expense, or because I feared that the autopsy would uncover an error. It was the opposite: I didn't see much likelihood that an error would be found. Today, we have M.R.I. scans, ultrasound, nuclear medicine, molecular testing, and much more. When somebody dies, we already know why. We don't need an autopsy to find out
22, 24: Doctors are way more professional than dilettantes and poseurs such as astronauts.
also something about coroners increasingly being elected officials who had little to no training in forensic medicine
Coroners can be elected or appointed, and the lack of medical training has always been that way in jurisdictions with coroners instead of medical examiners (in the US, at least; I don't know about other countries with coroner systems).
Anecdotally, my mom was in the autopsy biz, mostly as a medical examiner and therefore a state employee, but she did autopsies in the hospital morgue and associated closely with docs there, and I never heard about fear of malpractice suits as an excuse not to perform them. 2 sounds to me to be another case of James imputing malign motives to a class of people he doesn't like.
Astronauts use checklists. They don't like them:
Astronauts like windows, explosive bolts on the capsule door and most importantly substantial control of the "spacecraft":
27: I should ask Dr. Oops what she thinks -- before med school she was a diener (autopsy assistant) at a Boston hospital.
28: I think you'll find that the Mercury Seven were more than happy with check lists, having worked with them routinely in preflight checks as test pilots. The objection is to using them as a means of evaluation, and to making them the sole task of the Astronaut. The (ban me now!) analogy with surgeons is pretty good, actually - The checklist is just there to take care of remembering the details, allowing full concentration on the complicated part of the task. Nowadays I think you'd be hard pressed to find an Astronaut who didn't embrace them wholeheartedly.
An awesome doctor once told me that, based on the negative results from two tests she had just ordered (an MRI, a 30-minute EEG) plus the inconclusive results from some tests that had recently been done by other doctors (a 48-hour EEG, a few labs), she had been able to rule out all possible physiological causes for my (at the time, debilitating) symptoms and it was therefore all psychosomatic.
Later some other doctors thought of some other tests to do and ruled everything back in. Nobody gave me five dollars, and now I hate doctors.
If I'm reading you right, you're saying that sometimes illnesses flip back and forth between being psychosomatic and being real.
Clearly we need an autopsy to be able to get an accurate diagnosis.
I'm saying, I'm ALREADY DEAD. Bet you didn't see THAT plot twist coming.
Geez, I figured it out when you were talking about how your autopsy went.
27: 2 sounds to me to be another case of James imputing malign motives to a class of people he doesn't like.
Well I think that, too. But I also think there is evidence that what he says is probably correct per my links in 12. [Note that James says "part of the reason" and "paranoia"; he does not claim it is well-grounded.]
I'm late to the party with the autopsy results on the DE. She had severe coronary artery disease (including one artery completely blocked) missed by any number of docs and tests over the years. She even had a chemical stress test looking for cardiac problems specifically and passed with nothing showing. She never had any symptoms that would have prompted a cardiac cath until the first MI in November.
The intensive care docs asked if I would allow an autopsy, they didn't seem afraid of a lawsuit at all, and by then they knew I had the resources to bring one if I decided to do so.
Hey Biohazard,
Thank you for that update. The inability of modern medicine to catch things that you think it should can really pull you (meaning me) up short sometimes.
I really don't see how a fully blocked artery can be missed, but, of course, I'm not a doctor.
I hope that someone write into the New Yorker expressing something about the limits of our knowledge of the causes of death even w/ modern medicine.