Evidence-based medicine and health insurers generally focus on what’s medically necessary, not what’s epidemiologically relevant, not what soothes the mind of the bereaved or of the physician grieved and mystified by the loss of a patient. Once the autopsy was a venerated tool for medical advancement and humility. An invaluable means of learning one’s own limitations and the extraordinary diversity in nature and human physiology, it has now become an unreimbursed after-thought. An irrelevant thing, especially since the patient is already dead, there are living patients to care for, and people just need to “move on”. And it just doesn’t pay to know that your diagnosis premortem was wrong; it only adds fuel to the malpractice attorney’s fire, which further fuels already skyrocketing malpractice insurance premiums. In life, a diagnosis based on assumptions is unacceptable. There are tests that must be run, high tech imaging, much probing and invading. Yet in death, an assumed cause is what goes on the death certificate well over 90% of the time.
But what if the diagnosis was wrong? what if the examination missed something? What if a clue was misinterpreted? What if the guidelines-sanctioned pneumonia protocol didn’t work, and why? What if all the probing, and imaging, and blood draws didn’t yield the answer? These don’t indicate malpractice, they indicate a gap in knowledge. We should be thirsting for this knowledge, yet we throw away the opportunities to improve every day.
I propose that the autopsy is more relevant than ever. That the dead can indeed live and speak through a thoughtful pathologist’s hands and eyes. That more than ever, doctors need to know what they are missing with all the bells, whistles, drugs, and treatment guidelines at their disposal. I have never found an autopsy on one of my patients to be less than a profoundly humbling and highly educating experience.
Moreover, I have never experienced such reverence, humility, and deep gratitude than I did in reading my 10 year old son’s autopsy report. It was the very hardest thing I have ever read. Yet I felt for the pathologist who performed my son’s autopsy a gratefulness as profound as for the obstetrician who delivered him. Indeed, for a few moments of crystalline time, it was as if my son was given life and voice, reaching out through the dryly graphic account to tell the true story surrounding his death. That voice was resonant and life-altering, as pure and true as it was the first time I heard his cry.
I still think of the pathologist who performed his autopsy and drafted his carefully detailed report, with deep reverence and affection, for giving my son his voice. For giving me the gift of the truth. I keep his report in a memory book with Philip’s things.
Autopsy 101: The Decline in Autopsy Rates
[This post was first published on Infectious Bytes, the Blog, on August 28, 2011]