Who does not like autopsies and why?

Autopsies establish truth, detect change, provide hard data, instruct learners, and promote justice. Yet, they seem poorly valued in modern America except in many TV crime shows like “CSI.”

Dr. Donna Hoyert of the CDC, in August 2011, profiled the dramatic changes in American autopsy rates, noting that while forensic autopsies remain common, hospital autopsies for patients with diseases, especially in the elderly, have almost disappeared.

In evaluating medical quality, I often ask: “How do you evaluate the quality of care given to your sickest patients, the ones who die?”

Unless the answer “by autopsy” comes back quickly, I instantly fault that institution or agency.

Sadly, I rarely do get that answer.

Who does not like autopsies and why?

  1. Pathologists don’t like autopsies because they can be unpleasant, smelly, time-consuming, unappreciated, often not specifically paid for, and they take time away from other tasks viewed as more important, appreciated, pleasant, and lucrative.
  2. Clinicians do not like autopsies because it is uncomfortable to face a family that has lost a loved one. The physician must confront a level of failure because of the death, a tarnishing of the doctor-as-god image. Autopsy surprises might lead to an unhappy family, quality assurance committee concerns, possible litigation, and even a report to the state medical board.
  3. Hospital administrators do not like autopsies because they prefer not to dwell on unfavorable results of hospitalization. They claim difficulty finding the money to pay for them and can never make a profit from autopsies. They often have little medical or scientific background that would encourage curiosity and they tend to do mostly what licensing and accrediting agencies require; these remain strangely silent.
  4. Third-party payers do not like autopsies because they are an expense, and are performed on people who are already dead.
  5. Families of patients do not like autopsies because they are ill-informed about their value, afraid that it might cost them money, and some feel that the deceased person has already been through too much of an ordeal in dying.

So, it has devolved to a few leading physicians like Harvard’s Atul Gawande in The New Yorker and the popular media to recurrently raise the question of why don’t we have more autopsies.

The award winning news outlet ProPublica is issuing a series of remarkable reports by investigative journalists about how we as a society and as a profession handle death. See all of them, free of charge.

Regardless of their current low valuation, the autopsy remains the essence of modern clinical science. It is the one place where truth can be sought, found, and told without conflicts of interest.

Could any hospital have a serious patient safety initiative without a substantial autopsy rate? No, it could not. Maybe that is one of the reasons why the patient safety movement has failed to prevent serious medical errors in so many hospitals.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I couldnt agree with you more on this issue George. We need the oldfashioned PCP conferences to learn and improve. The conferences need to be protected by confidentiality and sovereign immunity since in Florida, trial lawyers were sending paid staff to troll these conferences for potential cases before these conferences disappeared from the CME and medical staff calendar. Cost is a factor as well. Nobody wishes to pay for them , not insurers and certainly not the institutions or family members. These conferences were humbling learning experiences that opened your eyes, broadened your differential diagnosis and resulted in more knowledgable and educated care.

  • Anonymous

    I don’t disagree that autopsies are clinically valuable, need to be done, and face some opposition in our current health care environment.  However, to play devil’s advocate, there are circumstances where autopsy is of little to no clinical interest, and I suspect that with our aging population, these scenarios are becoming more frequent.  An example would be an 85+ year old patient with advanced dementia and long standing severe heart failure.  This is not an especially uncommon scenario, and it is a travesty if a patient in these circumstances is not essentially receiving comfort care only.  When such a patient dies, it is not unexpected and typically, there is no real mystery about it, whether death occurs at home, in long term care, or at a hospital.  In counseling the family of such a patient, I would of course mention autopsy as it is a part of routine procedures, but I doubt that I would want one done if I were in their shoes, and the focus of my counseling would be facilitating grieving and letting go rather than the importance of autopsy.  Not to say that there might be research value in such autopsies, in understanding normal and pathological aging processes, but clinically, I can’t imagine what such an autopsy could really change.    

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