July 23, 1999 (Ira Pilgrim
A disease which is new and obscure to you, Doctor, will be known only after death; and even then not without an autopsy will you examine it with exacting pains. But rare are those among the extremely busy Clinicians who are willing or capable of doing this correctly.
Hermann Boerhaave(1668-1738)
I have been told that when a hospital wanted to inform the staff that there would be an autopsy, the public address system would say "Paging Dr. Mortimer Post." In response to this, students, interns, residents and staff doctors who wished to attend the autopsy, would go to the morgue. It was also the custom to notify the physician whose patient was being autopsied. The pathologist who does the autopsy always has the last word, and it behooves anyone who wants to improve his understanding of medicine to pay close attention.
My own contact with autopsies occurred when I briefly served as the pathologist's assistant in an army hospital in Riems, France.The high point of my career was when I was watching the autopsy of a man who had died less than an hour before. It looked to me as if the man breathed and I said so. Two doctors jumped to the table; one felt for a pulse and the other listened to his chest. Then they turned to look at me and the foolish expression that I must have had on my face. From then on, before an autopsy, the pathologist would ask, "Pilgrim, is he dead?"
I learned a good deal at those autopsies, as does every medical student and physician who wishes to grow in his profession. Autopsies are still an important teaching tool. It was considered so important that no teaching hospital would be accredited unless a certain percentage of the deaths occurring in the hospital went to autopsy. Not any more. Autopsy rates are way down and the only autopsies that are routinely performed are coroner's cases. These are people who died under mysterious or criminal circumstances or were not in a physician's care at the time of their death.
Any physician can certify to the cause of death of his patient. His diagnosis of the cause of death may be right, or it may be wrong. He will never know. This may not be of much importance in a very old person, but it is very important in the death of someone young or middle aged.
In these days of high-tech medicine, it is assumed that diagnoses are much more accurate than they used to be. This is true, but they are far from 100%.
The problem with having few autopsies is that a physician who makes a mistake may never know it, and may well repeat that same mistake. Every physician makes mistakes. The best docs learn from their mistakes and don't make the same ones again. At least they don't make the same FATAL mistakes.
I used to attend surgical conferences at the University of Utah Medical School. I remember a professor of surgery saying, "We killed this one." When I needed surgery, he was the one I went to. Only a first rate surgeon could afford to be that honest.
This decrease in the number of autopsies is of major concern to many physicians. In a series of articles in the Journal of the American Medical Association and in the British Medical Journal, this problem was addressed. One suggested that MRI be used since it should be acceptable to relatives.It is not as good as an autopsy, but it is the next best thing. One major problem is who is going to pay for it? The problem of who pays for autopsies is a major one. I would like to see autopsies federally funded. The justification would be that it is essential to the education of physicians. An autopsy is of no help whatever to the patient. However, it may save the life of the next patient with a similar condition.
Another major problem has to do with the information falling into the hands of lawyers who can make big money out of a doctor's mistake; even an honest and unavoidable one.We can be sure that the best doctors make mistakes. How many must the worst ones make? The poorer physicians have reason to be afraid of more autopsies. The best physicians would welcome them.