Losing chance to learn from dead Autopsy: The procedure has been an abundant source of medical knowledge for centuries. But in medicine's modern era, the autopsy is dying -- a victim of economic and technological change.

Sun Journal

September 23, 1998|By Laura Beil | Laura Beil,DALLAS MORNING NEWS

DALLAS -- For five days, the baby endured a hacking cough and runny nose. When her fever suddenly spiked to 104 degrees, her parents dashed to the emergency room.

Viral myocarditis, her doctors thought -- a rare ailment that develops after an ordinary virus wriggles into the heart. The body's immune system, in a desperate rally to clear the infection, attacks the very organ it is trying to save. Hours later, the child died.

The grieving family asked for an autopsy.

The findings astounded and distressed the doctors: The infant had fallen not to the tactics of a virus, but to dangerously contagious bacteria. And by now, two toddlers from her day-care center lay in bed, inexplicably sick. Immediately, they received antibiotics.

"That autopsy saved the lives of two other children," recalls Dr. Dennis Burns of the University of Texas Southwestern Medical Center at Dallas.

Autopsies have been a rich source of medical knowledge for centuries. Without such examinations, doctors say, the living lose their best chance to learn from the dead. But now many experts lament a disturbing trend: In medicine's modern era, the autopsy is dying, a victim of economic and technological change.

In 1964, 41 percent of deaths at U.S. hospitals received a postmortem examination, according to a 1978 study. In 1994, government statistics put the figure at 9 percent. Even in many medical schools, pathologists say, future doctors can graduate without a detailed look at the handiwork of disease.

Much of the decline has to do with medicine's increasingly sophisticated vocabulary, such as PET scans, MRIs and other imaging techniques. In the face of technology, the autopsy is sometimes viewed as an artifact from another time.

Economics is also a conspirator. While the cost of the procedure -- which can range from about $1,500 to $3,000 -- doesn't usually fall to the family, a hospital must pay for the overhead, and increasingly rushed doctors must set aside valuable time.

Some pathologists also speculate, although studies have not confirmed, that bedside physicians may not encourage autopsies for fear that some new discovery about a patient's condition might prompt a malpractice suit.

Hospitals and physicians have little incentive to obtain autopsies, pathologists and other doctors acknowledge. The Joint Commission on Accreditation of Healthcare Organizations, which certifies hospitals, has not required autopsies on patients since 1971. Doctors studying to be pathologists used to be directed to perform 125 postmortems during their training. In 1989, that number was dropped to 75. Doctors choosing other specialties have no particular autopsy requirements.

As a result of these and other factors, many doctors worry that potential medical discoveries are literally buried every day. Although million-dollar machines can peer into working organs, and molecular biologists can scrutinize individual cells and genes, the autopsy remains the last word in the diagnosis of disease.

"The autopsy is the truth," says Dr. Stephen McPhee, an internist at the University of California, San Francisco. "This is as close to the truth as we get."

Not only can autopsies teach more about familiar diseases, they can uncover new ones. Through autopsies, doctors can discover unexpected effects of drugs or alert the community to emerging infections.

"We're fooling ourselves if we think we really understand the nature of many deaths," says Dr. David Relman, a Stanford University physician. He works with a federal program that examines fatalities with unexplained causes, a kind of "X-Files" for public health. Studies have suggested that each year, about nine of every 100,000 otherwise healthy Americans under age 50 are killed by an unanticipated, mysterious illness.

The autopsy is "absolutely critical to understanding how, why, when and where new diseases appear," Relman says. For example, autopsies helped to quickly identify hantavirus pulmonary syndrome, a respiratory illness spread by rodents that first gripped the Four Corners region of the Southwest in the early 1990s.

But even when doctors think they can explain why a person died, the autopsy can be a reminder of human and technological fallibility.

"Clinicians tend to have the belief that with sophisticated technology, they already know everything about the patient there is to be discovered," says Dr. Peter Baker of Ohio State University, chairman of an autopsy committee for the College of American Pathologists.

Yet studies have found that the frequency of misdiagnosis has changed little in three decades, even with new technology. German researchers recently examined records from 400 autopsies conducted between 1959 and 1989. They found that rates of misdiagnosis hovered around 10 percent to 12 percent.

Baker published a study in 1993 reporting that 40 percent of autopsies reveal at least one major unexpected finding, although it may or may not have made a difference in the patient's care.

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