Reviving the autopsy

How an old procedure fell out of fashion

Emory University Medical School's morgue is coming to life. Since January, rather than merely reviewing autopsy findings, residents and faculty are now required to discuss whether autopsy results agree, disagree or strongly disagree with what a physician has listed as cause of death.

It may sound like a typical med school course, but it's not. Once a standard procedure, the non-forensic autopsy — the kind that does not involve a crime or suspected foul play — has become an anomaly.

According to the National Center for Health Statistics, autopsies were performed in about 13 percent of deaths nationwide in 1984. That percentage dropped to 9.4 in 1994. The center doesn't have more recent figures. Funding shortages forced the center to choose what was more important: marital status at time of death or whether an autopsy was performed. The autopsy lost out, and so did we. Besides being a valuable teaching tool, autopsies can be an endorsement — or an indictment — of a doctor's diagnosis.

In February, the Cleveland Clinic in Ohio released disturbing results of a study of several hospitals: Forty percent of autopsies revealed that initial diagnoses had been wrong. Of those, a full third were so wrong that had the patient been treated properly for what actually caused the death, he or she would have lived. The Cleveland study echoed earlier studies at the University of Pittsburgh, Penn State and Louisiana State University.

George Lundberg, a pathologist and former editor of The Journal of the American Medical Association, estimates that autopsies are performed in only 5 percent of deaths at most hospitals.

"We need autopsies to teach the doctors and the medical students," says Lundberg, who is now editor of the online publication Medscape in New York. "We need them to be able to tell the family the truth and to otherwise do the right thing."

In Atlanta, two of five hospitals questioned — Piedmont and Grady — failed to provide autopsy numbers. Those that did answer CL's request — St. Joseph's, Northside and Emory — reported numbers that mirrored the national trend. St. Joseph's performs the fewest, less than 1 percent of in-hospital deaths, because a majority of its patients are elderly with long-term illnesses, according to spokeswoman Diana Lewis. Northside performs autopsies in more than 15 percent of its deaths. That's primarily because it specializes in high-risk pregnancies, according to spokeswoman Katherine Watson. Stillbirths are often autopsied so that doctors can determine what went wrong during the pregnancy or if there was some congenital defect. Emory performs autopsies in 13 percent of its deaths.

Autopsies have been on a slow slide since the 1960s, as medical technology improved and doctors' confidence grew. The number of autopsies plummeted even further in the 1980s when managed care dictated cost-cutting measures and hospitals deleted autopsies as an unnecessary expense.

But their fiscal decision is misguided, says Lundberg, whose new book, Severed Trust, includes a chapter on the demise of the autopsy in American medicine.

Elderly patients account for about 75 percent of deaths at hospitals. While some might argue that there's no point in spending an average of $2,000 or $3,000 to autopsy a patient who died after battling one of the "Big Three" — pneumonia, heart attack or stroke — Lundberg says Medicare pays for an autopsy. The money set aside by Congress (though not specifically marked in the voluminous Medicare regulations) is being used by hospitals for other things. Families don't know the procedure is paid for so they don't ask about it.

Most doctors agree that an autopsy isn't necessary in every case, and most elderly patients' deaths don't hold any surprises.

But Inga Lindsey Fridie, an assistant professor of pathology at Morehouse School of Medicine, says she's seen autopsies that showed that doctors were completely off base, and obviously she's not alone.

Consider the case of Donald Ice of Morrow. Ice, a 63-year-old man who smoked three to six packs of cigarettes a day for 40 years, complained of nausea and pain in his left shoulder after painting a house. Dr. George Brown at Georgia Baptist Hospital's Family Practice Center diagnosed him with a left rotator cuff injury and a stomach virus. Ice, though, was right-handed. Two days later, he was dead.

Wayne Grant, an Atlanta attorney who's handled medical malpractice lawsuits for nearly 20 years, won a $250,000 judgment in 1998 against Brown and Georgia Baptist Hospital (now under new ownership as Atlanta Medical Center).

The autopsy — which showed Ice had died of a heart attack — was crucial in convincing the jury of a misdiagnosis, Grant says. In fact, he usually doesn't take a wrongful death case unless there's an autopsy. The requirement diminishes his caseload, considering how few autopsies are done, but it boosts his success rate.

"It makes all the difference in the world," Grant says. The opposite is also true. In cases without an autopsy, doctors and hospitals might invoke the "So what?" defense.

"They say, 'He would have died

anyway,' " Grant says. "You hear it in almost every case without an autopsy."

Medical malpractice judgments grab headlines and feed talk show mills. They probably also provide an inadvertent financial incentive for hospitals not to do autopsies. Why assist in your own indictment? Lundberg counsels that, despite the threat of a lawsuit, it's better for the medical community as a whole if doctors and hospitals do autopsies, learn the truth and, if they've made a mistake, settle with the family as soon as possible.

Autopsies, though, are most important in teaching doctors what to look for in future cases.

At Emory, pathologist Randy Hennigar says the school's more stringent autopsy conference will do more than teach future doctors to train a critical eye at the cause of death. Their findings, including how often diagnoses were wrong and why, will be recorded and tracked so that Emory can gauge the importance of autopsies in determining cause of death. While medical technology has made performing an autopsy redundant in some cases, Hennigar says, the procedure is still the best way to really know what killed a patient.

So, when 10 to 20 residents gather around an autopsy table in Emory's morgue this week to look at organs removed during last week's autopsies, they'll be doing something "retro." They'll be reversing a trend inspired by technology and managed care. And they'll be keeping medical arrogance in check and medical inquiry alive.??