Wednesday, May 18, 2011

Andrew Sullivan Continues his Anti-Physician Drumbeat

The Cause Of Death: Greed?
Earlier this week, Michelle Andrews reported that "hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s." She also dug up a 1998 report that found "autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time." Robin Hanson has a theory:

A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. ... Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

That was from one of his blog-link posts this morning. Let me first deconstruct the incoherence of the assertion of the title---> "The Cause of Death: Greed?" I mean seriously. What is being scrutinized here is the decrease in autopsies that are performed in American hospitals over the past 50 years. What on earth does that issue (worthy of investigation, certainly) have to do with greedy physicians being the cause of those patients' deaths? If the patient is already dead, then what does the relative generosity of a physician have to do with what caused his death, in the context of whether or not an autopsy is done? Let's say an autopsy would reveal that the physician made an error and he wants to conceal that fact by quashing an autopsy, then one could make the assertion that the physician is acting greedily by seeking to reduce autopsies and enhance his reputation amongst peers/patients. But by no means can one use such behavior to infer that the physician also caused the patient's death through avaricious conduct. It's a malicious, misleading headline that attempts to re-assign after the fact vices as the precipitating factor that led to the event in question. In other words, if a kid knocks over his aunt's thousand dollar Chinese vase and attempts to cover it up by lying because he knows she will make him pay for it you could rightly infer that his greed led to his deceitful post-event behavior. But you wouldn't ever state that the kid's greed led to the vase getting knocked over in the first place would you?? It's absurd.

The piece furthermore leads the casual reader to infer that doctors are engaged in a nation-wide conspiracy to cover-up the causes of death in hospitals, like some cheesy Robin Cook novel. Do you think this is true? Are doctors actively trying to talk family members out of autopsies on their dead loved ones? I don't think so. I know for damn sure if I lost a loved one in the hospital and a bedraggled doctor immediately tried to talk me out of getting an autopsy, the first thing I would do would be to demand an autopsy STAT. I think the fact that fewer autopsies are performed has less to do with doctor practices/behaviors than with our preferences as a society. We aren't comfortable with actual death (unless it's the patriotic, hyper-violent, glorified kind you see in video games and American pop culture). It's a sociocultural issue. We can let Malcolm Gladwell figure that one out. The reality is, when someone dies in the hospital, a doctor has to fill out the death certificate. On that certificate, we have to indicate whether or not the incident qualifies as a coroner's case (mandatory autopsy) and whether or not the family decided to pursue an autopsy.

The article Sullivan links to contains this paragraph:
Autopsies play a critical role in helping to advance understanding of the progress of a disease and the effectiveness of various treatments. At the same time, they may identify medical conditions that clinicians and high-tech imaging miss or misdiagnose. For example, Elizabeth Burton, deputy director of the autopsy service at Johns Hopkins Hospital in Baltimore, recalls that when she autopsied a 50-year-old alcoholic patient, what appeared to be cirrhosis of the liver was actually cancer.

You know what a risk factor for liver cancer is in this country? Cirrhosis, either from alcohol or viral hepatitis. So in the above example, the autopsy revealed something that, although undiagnosed at the time of death, didn't necessarily cause the patient's demise (almost certainly the cirrhosis did) and is a clinical finding most clinicians would find unsurprising.

In the 1960's we often had no idea why in the hell people died. We didn't have CT scans or coronary angiography or high tech hemodynamic monitoring devices like we do today. Nowadays we can explain to patients with a reasonable degree of certainty that patient X died "likely due to condition X, Y, and Z." Autopsies in the 60's gave families and doctors closure. A family member just wants to hear something other than "I don't know what happened".

I'm a Sullivan fan, generally (torture, Palin, etc). But he's out of his league on the health care issue.


DocInKY said...


Couple of points:

There is the issue of paying for the autopsy that comes up - Not a given today. Many families do not see the value when, as you noted, the CT/Angio/MRA/Biopsies/ Panendoscopies have told all before the demise.

And second, the coroner in many places does not mandate an autopsy just because it is referred to the coroner. I have called the coroner on death after an attempted ruptured AAA repair and have been told "Okay, I'll just release the body..."

I think the cost versus reimbursement issue makes many pathology departments not wanting to cover the expense.



Anonymous said...

Oh nevermind. Purposeful ignorance just makes me crazy.

Anonymous said...

The only time I've ever talked about autopsies with the docs I work with they were disappointed that the rate of autopsies had decreased. They don't get done as much because there isn't the money for it. It's weird and pretty creepy that he thinks it is some sort of conspiracy.

Anonymous said...

Everyone is all about cutting health care costs, yet his guy seems genuinely pissed off that more money isn't being spent on autopsies? I see it as a good thing. A suspicious death definitely warrants an autopsy, but otherwise they waste the limited medical resources that we have.

Anonymous said...

Fo Sho, Fo Sho,
Andrew Sullivan knows about as much about Medicine as he does about Vaginas...
OK, I'm sure he knows how to say "Penis" in 800 different languages..
and autopsies are pointless in todays high tech age and for those cool scenes in "Dexter"
Seriously, you'd have some 19 year old gang banger shot in the eye, Moe Green Special Style, and they'd be doin frozen sections on the dudes adrenals...
don't wanna miss a case of ummm wateva ya call those adrenal diseases...
OTOH, without Autopsies we'd never have known Michael Jackson was Bald...


Anonymous said...

in my experience in the ED, autopsy is refused for most deaths. when i offer, the family says no because knowing what killed them won't bring them back. sounds reasonable to me.

swag said...

I used to try to get autopsies on almost all deaths. In the 70's an autopsy rate of 25% was the goal. Then in the 80's, one of the primary care doctors at our hospital was sued for missing pulonary emboli, based on the autopsy. Most of the doctors at that hospital quit asking for autopsies. I still try to get them when I'm confused about the outcome, but it's not a common practice.

Chuck Sheaff, general surgeon