Saturday, December 29, 2012

Death of the Autopsy

In the decades of the 50s, 60s and 70s the autopsy rate gradually diminished until the present time when the indication for post mortem examination is now largely confined to forensic reasons leading often to inquests, or sudden unexplained death within 24 hours of hospital admission: almost always ordered by the coroner or court. Why this particularly useful examination has been discarded as a frequent assessment in the past of the utility of treatment ; an overview of disease and disorders commonly missed in diagnosis and treatment; and as a teaching tool in clinical-pathological conferences to enlarge the diagnostic acuity of the clinicians and students; can be surmised in the light of the litigation sensitive time we live. As a result we have trouble claiming a unbroken willingness to pursue all avenues of evidence based science in the interest of developing continuing patient care. I am sure that my practicing colleagues would say, "It's OK for you to espouse this now because you are no longer in practice!" Fair enough! Still, there are a lot of other reasons routine autopsies are not more frequently done. The deceased's family is unwilling to have their loved one's body subjected to autopsy for reasons of pure science. The hospitals on tight budgets are unwilling to add further expense that would compromise immediate needs. There is an acute shortage of pathologists and a complete autopsy is very time consuming. The provincal governments are unwilling to increase the allocation for non-treatment expenses. Physicians erroneously believe the sophisticated imaging of today is a satisfactory replacement for a comprehensive autopsy, or at least good enough as a routine. Physician insurance and hospital insurance companies would be reluctant parties to expanded autopsies that might increase the number of litigants based on hitherto uncovered live data. Let sleeping dogs lie is in order. Maybe that is so. Good medical care still exists in this country where informed consented risk taking by physicians is practiced, rather than cherrypicking only easy cases and offloading the more  risky. All these factors come into play and evidence based science is the loser as a result. And so, in fact is the patient in the end when the doctors are often having to look over their shoulder. Whoever might win are the lawyers and the chronically disgruntled! Oh well, easy for me to say. I still remember with fondness the cut and thrust of the clinical path conference with the clinician pitted against the pathologist: the clinician attempting a rational assessment of a patient, unknown to him, but with all the clinical records available, in the bright glare of his colleagues and students, thereby exposing his diagnostic acumen or lack thereof, before the autopsy findings were finally revealed. What a way to learn to think systematically and still remain humble!

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