The New York Times - September 13, 1983
Lawrence K. Altman, M.D.

Many medical leaders, like Dr. George M. Lundberg, editor of The Journal of the American Medical Association, now regard the decline in autopsies as deplorable. They firmly suspect that it is behind recent studies indicating that the percentage of correct diagnoses is actually declining in many hospitals in the United States, despite the development of CAT scanners, ultrasound and other sophisticated diagnostic equipment. These medical leaders and those in other countries believe there is a general relationship between the number of autopsies performed and the accuracy of medical diagnoses - that the discipline of a pathologist checking the accuracy of a clinical diagnosis carries over to the clinician's care of the next patient.

One development the medical critics are particularly upset about is that autopsy rates are no longer even part of the hospital accreditation process in the United States. Another is that the rate decline is especially sharp in deaths of the elderly, and it is in this category that the misdiagnoses are especially high.

Obviously, an autopsy is done too late to help the dead. But it can have critical importance in helping doctors to understand the cause of death and in detecting unsuspected conditions. It may well prevent the illness or premature death of others. This is particularly true of ailments that are caused by microorganisms, environmental factors and heredity. For example, some recent cases of tuberculosis that were recognized only at autopsy have led families to take protective steps against the TB infection.

The primary purposes of an autopsy are to establish a cause of death and to compare it with the clinical diagnoses - those made when the patient was alive. Society gives forensic medical examiners legal powers to perform autopsies on people who die under unusual circumstances. Through such efforts, these public officials can detect murders, suicides, new diseases or unrecognized problems vital to the health of the public. But the current problem centers on deaths among patients in hospitals or nursing homes who have been diagnosed and treated for long periods but for whom there would be no reason to call in a medical examiner.

Autopsies serve many more purposes. For one, they provide the data that allow us to understand the natural history of a disease. Autopsy studies are one of the most important ways by which researchers hope to solve the mystery of the deadly new disease called acquired immune deficiency syndrome, or AIDS. A report from the National Institutes of Health in September's American Journal of Pathology describes the type of cell damage in organs as well as the patterns of unusual infections affecting 10 AIDS patients, but such studies simply cannot be done on the living.

Patterns that emerge from autopsy studies serve to monitor the public health and the quality of medical care. Beyond that they provide the vital statistics that determine how the Government spends taxpayer money and sets policy. If too few autopsies are done, a nation's vital statistics may be flawed and it may set the wrong priorities and wrong policies.

Ironically, the decline in autopsies comes at a time when the examination can be more valuable than ever to blood relatives. More and more common disorders are now known to have a hereditary component or are suspected of having one. Consider Wilson's disease, a fatal hereditary disorder in which abnormal amounts of copper accumulate and destroy the liver and the brain. The symptoms of the disease can mimic a wide variety of liver, neurological and psychiatric conditions. But these symptoms, which usually appear in adolescents, may sometimes be delayed until age 40 or later - and the disease is fatal unless treated early on with a drug called penicillamine. If the diagnosis is not too late, and if proper treatment begins soon enough, the patient can have a normal life span.

Wilson's disease can be detected through blood and other tests in the living but sometimes is diagnosed only in an autopsy. Dr. I. Herbert Scheinberg of the Albert Einstein College of Medicine in the Bronx, an internationally recognized expert in Wilson's disease, said he could recall at least eight cases in which the diagnosis was first made at autopsy. In all eight cases, the information saved the lives of siblings or other relatives.

When autopsies reveal hereditary disorders, families often benefit from genetic counseling as well as from the medical facts that can help relatives avoid misdiagnoses and resulting treatments that can be dangerous.

Why are more autopsies not done? The resistance seems to come as much from doctors as from the relatives of patients and the public. Many doctors have argued that autopsies are no longer needed because blood tests and biopsy techniques are so precise that they basically provide a miniautopsy while the patient is alive. But studies have shown that this is not always so.

In a study of 100 consecutive cases of autopsy-proved heart attacks at Baptist Memorial Hospital and the University of Tennessee College of Medicine in Memphis, the correct diagnosis of heart attack had been made in just 53 percent of the cases. This compared to figures of 65 percent in 1938, 57 percent in 1948, 69 percent in 1957 and 61 percent in 1959, according to The Journal of the American Medical Association. Surprisingly, these figures came from times when blood and other diagnostic tests for heart attacks were considered less precise than they are now. However, at least one expert in heart pathology has cited some flaws in the Memphis study that suggested that some comparisons to earlier years may not be entirely valid.

The errors are not limited to heart attacks. Doctors at the Brigham and Women's Hospital in Boston reported earlier this year that advances in diagnostic technology have not reduced the value of the autopsy. Results of 100 randomly selected autopsies from each of the years, 1960, 1970 and 1980, showed that about 10 percent revealed a major condition, undiagnosed during life, that could have been treated so as to have prolonged life.

Feelings against autopsies run high among people who recall rude or tactless approaches taken by some doctors in requesting permission to perform them on members of their families. That situation was much more common when keen competition existed among doctors to get the highest autopsy rates for their teams.

Doctors themselves often have differences of opinion about a pathologist's diagnosis, and refuse to accept it as final.

Beyond that, some doctors may be reluctant to press for an autopsy because of the fear that it might reveal a serious medical error, which could result in a lawsuit. Clearly, the autopsy could prevent unwitting repetition of the same mistakes. But, as Dr. Lundberg has said, the time has come for doctors to "stop burying their mistakes."

It is difficult to understand how patients can trust the practice of medicine in hospitals that have low autopsy rates. Certainly, autopsies may not be needed in every case. But if more autopsies were done, and the accuracy of diagnoses were established more often, the public would have good reason to have more faith in their practicing physicians.

The American health care system is based on fees for service, and that incentive is often lacking in autopsies, since only rarely are doctors paid for them. Medical journals reports have said that autopsy costs are not reimbursable to hospitals. But Dr. Lundberg of The Journal of the American Medical Association disagrees. "The allegation that there is no money to pay for autopsies is a cop-out," he said, noting that the Medicare program and many private health insurance plans will reimburse hospitals.

Many of the important costs of doing autopsies cannot be measured only in money. Pathologists have long said that much can be learned about how a society lives by studying how its members die.

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