Death of the Autopsy
New Scientist.
13th November, 2006
Doctors occasionally kill their patients instead of curing them. It’s not a secret and this may be by prescribing the wrong drug. Serious efforts are now being made to reduce medical errors, but the focus is almost entirely on avoiding mistakes in treatment, rather than in the original diagnosis. Major mistakes in diagnosis do happen, and they are surprisingly common. It is estimated that as many as 1 in 20 patients who die in hospital, do so because their illness was misdiagnosed.
The best way of uncovering diagnostic errors (autopsy) is in steep decline. If a misdiagnosis is not suspected, then evidence will be buried or cremated with the body, and nobody will be any the wiser. There is nothing to stop the same mistakes being made over and over again. "Diagnostic errors do not receive the attention they deserve," says Kaveh Shojania of the University of Ottawa in Canada, who studies medical errors. "It is a big part of the problem."
The value of autopsies was established during the 18th and 19th centuries and today remains the gold standard as a way for doctors to identify and learn from their mistakes. It is much easier to find out for sure what was wrong with someone after their death as pathologists can cut open the body, examine any part in detail and take samples for testing.
Suspicious circumstances
Some forensic or coroners' autopsies have to be done for legal reasons and are often where the cause is unclear or are required after violent, accidental or suspicious deaths.
Sometimes, doctors just want to know more about why someone died.
One of the first large studies (1912) compared hospital autopsy results with the initial diagnosis. After looking at 3000 cases it became clear that nearly half the diagnoses had been wrong. Today's performance seems little better and a recent review of similar studies since the 1960s concluded that the certified causes of death were wrong in at least a third of cases. At least 10 per cent of autopsies show patients might have lived had their diagnosis been right and, although not all the errors would have affected survival, some would.
Health policies are often based on death certificate statistics.
The conclusion was reached that the accuracy of diagnoses has been improving steadily, with the rate of major discrepancies affecting survival falling by a third each decade (Journal of the American Medical Association, vol 289, p 2849). However, the death rate remains high. At least 4 per cent of all US patients who die in hospital might have survived had their diagnosis been right. The figure is higher in other countries.
Even in today's era of high-tech medicine, some errors are inevitable. Doctors have limited knowledge, limited tools and limited time to make a diagnosis and even well-studied diseases can produce strange symptoms unlike those in the textbooks. Patients can also have several diseases at once. It is sometimes not possible to work out what is wrong with a patient while they are alive, and not always possible when they are dead either. "It's a miracle how often doctors get it right," says Mark Graber of the Veterans Affairs Medical Center in Northport, New York.
An important cause of error was mistakes by individual doctors and these ranged from lack of medical knowledge to using flawed reasoning to reach their diagnosis. The commonest type of error is "premature closure": a doctor arrives at a diagnosis that seems to fit the facts, then stops considering other possibilities. Some doctors gave every sign of sheer incompetence, such as failing to pass on test results or even skipping parts of a physical examination. Whatever the cause of misdiagnoses, nothing can be done about them if they are never discovered. And the only sure way to detect more diagnostic errors is to do more autopsies. Whether it be flawed reasoning or faulty equipment, "No lesson is as powerful as seeing your own mistakes," says Graber.
The number of autopsies is in decline and clinicians don't think it necessary to conduct them. And it's no longer part of training. Cash-strapped public healthcare systems often decide the money is better spent elsewhere and private hospitals cannot charge relatives for autopsies so they have little incentive either. Another possible cause is increasing fear of litigation, but some argue that such worries are groundless. A recent study of US appeals court records showed that the crucial factor in law is not whether an autopsy reveals a discrepancy, but whether the misdiagnosis was due to negligence. "It is not necessary to be right," says lead author Kevin Bove of Children's Hospital Medical Center in Cincinnati. "You just have to do the right thing."
Others argue that doctors may not request autopsies in cases where they suspect they could be held liable for negligence.
Then there is the issue of getting consent from relatives. In the UK, there was public revulsion in 1999 on the discovery that a pathologist at Alder Hey Children's Hospital in Liverpool had stored thousands of organs from children's autopsies without their parents' knowledge. There have been similar public outcries about stored organs in Australia and Ireland. "Some doctors are now frightened to ask for consent," says Emyr Benbow, a pathologist at the University of Manchester in the UK. An audit at University Hospitals of Leicester before and after the Alder Hey scandal revealed the hospital autopsy rate had dropped from 10 per cent to less than 1 per cent.
The main cause was not that relatives were refusing consent; it was that doctors were less likely to ask for it.
Protection from lawsuits would be unlikely to go down well with an increasingly litigious public, but if doctors keep quiet about misdiagnoses, as may happen now, there is no chance of improving matters. Ideally, autopsies would be carried out on a random sample of people who die. In the US, hospitals once had to have a minimum autopsy rate of 20 per cent, but this was abandoned in 1970. In the UK, the Royal College of Pathologists once considered trying to push for a minimum 10 per cent random autopsy rate, but the Alder Hey scandal kicked the idea into touch. "There would be a substantial outcry," says Benbow.
If one of your family dies and a doctor suggests an autopsy, give permission.
Anatomy of an autopsy
The pathologist first examines the outside of the body. Then they make a large Y-shaped incision from the shoulders to mid-chest and down to the groin. There is almost no bleeding as the heart has stopped beating and there is no blood pressure.
The flesh is pulled back so the doctor can cut away and remove the breastbone and ribs to allow access to the chest cavity. They remove all the major organs, such as the heart and lungs, and many smaller ones such as the thyroid gland, for weighing and further examination. The stomach contents are checked for any drugs or poisons, and many tissue samples are preserved so they can be inspected under the microscope. If the brain needs examining, the pathologist cuts open the scalp from ear to ear and peels back the skin. Then they saw off the top of the skull to remove the brain.
At the end, all the organs except those portions that need to be saved may be returned to the body cavity, and the flesh is sewn up. The scalp incision will be concealed by the pillow when the dead person is in their coffin, so relatives will see no visible reminder of the autopsy.
Based on an article by Clare Wilson
13th November, 2006
Doctors occasionally kill their patients instead of curing them. It’s not a secret and this may be by prescribing the wrong drug. Serious efforts are now being made to reduce medical errors, but the focus is almost entirely on avoiding mistakes in treatment, rather than in the original diagnosis. Major mistakes in diagnosis do happen, and they are surprisingly common. It is estimated that as many as 1 in 20 patients who die in hospital, do so because their illness was misdiagnosed.
The best way of uncovering diagnostic errors (autopsy) is in steep decline. If a misdiagnosis is not suspected, then evidence will be buried or cremated with the body, and nobody will be any the wiser. There is nothing to stop the same mistakes being made over and over again. "Diagnostic errors do not receive the attention they deserve," says Kaveh Shojania of the University of Ottawa in Canada, who studies medical errors. "It is a big part of the problem."
The value of autopsies was established during the 18th and 19th centuries and today remains the gold standard as a way for doctors to identify and learn from their mistakes. It is much easier to find out for sure what was wrong with someone after their death as pathologists can cut open the body, examine any part in detail and take samples for testing.
Suspicious circumstances
Some forensic or coroners' autopsies have to be done for legal reasons and are often where the cause is unclear or are required after violent, accidental or suspicious deaths.
Sometimes, doctors just want to know more about why someone died.
One of the first large studies (1912) compared hospital autopsy results with the initial diagnosis. After looking at 3000 cases it became clear that nearly half the diagnoses had been wrong. Today's performance seems little better and a recent review of similar studies since the 1960s concluded that the certified causes of death were wrong in at least a third of cases. At least 10 per cent of autopsies show patients might have lived had their diagnosis been right and, although not all the errors would have affected survival, some would.
Health policies are often based on death certificate statistics.
The conclusion was reached that the accuracy of diagnoses has been improving steadily, with the rate of major discrepancies affecting survival falling by a third each decade (Journal of the American Medical Association, vol 289, p 2849). However, the death rate remains high. At least 4 per cent of all US patients who die in hospital might have survived had their diagnosis been right. The figure is higher in other countries.
Even in today's era of high-tech medicine, some errors are inevitable. Doctors have limited knowledge, limited tools and limited time to make a diagnosis and even well-studied diseases can produce strange symptoms unlike those in the textbooks. Patients can also have several diseases at once. It is sometimes not possible to work out what is wrong with a patient while they are alive, and not always possible when they are dead either. "It's a miracle how often doctors get it right," says Mark Graber of the Veterans Affairs Medical Center in Northport, New York.
An important cause of error was mistakes by individual doctors and these ranged from lack of medical knowledge to using flawed reasoning to reach their diagnosis. The commonest type of error is "premature closure": a doctor arrives at a diagnosis that seems to fit the facts, then stops considering other possibilities. Some doctors gave every sign of sheer incompetence, such as failing to pass on test results or even skipping parts of a physical examination. Whatever the cause of misdiagnoses, nothing can be done about them if they are never discovered. And the only sure way to detect more diagnostic errors is to do more autopsies. Whether it be flawed reasoning or faulty equipment, "No lesson is as powerful as seeing your own mistakes," says Graber.
The number of autopsies is in decline and clinicians don't think it necessary to conduct them. And it's no longer part of training. Cash-strapped public healthcare systems often decide the money is better spent elsewhere and private hospitals cannot charge relatives for autopsies so they have little incentive either. Another possible cause is increasing fear of litigation, but some argue that such worries are groundless. A recent study of US appeals court records showed that the crucial factor in law is not whether an autopsy reveals a discrepancy, but whether the misdiagnosis was due to negligence. "It is not necessary to be right," says lead author Kevin Bove of Children's Hospital Medical Center in Cincinnati. "You just have to do the right thing."
Others argue that doctors may not request autopsies in cases where they suspect they could be held liable for negligence.
Then there is the issue of getting consent from relatives. In the UK, there was public revulsion in 1999 on the discovery that a pathologist at Alder Hey Children's Hospital in Liverpool had stored thousands of organs from children's autopsies without their parents' knowledge. There have been similar public outcries about stored organs in Australia and Ireland. "Some doctors are now frightened to ask for consent," says Emyr Benbow, a pathologist at the University of Manchester in the UK. An audit at University Hospitals of Leicester before and after the Alder Hey scandal revealed the hospital autopsy rate had dropped from 10 per cent to less than 1 per cent.
The main cause was not that relatives were refusing consent; it was that doctors were less likely to ask for it.
Protection from lawsuits would be unlikely to go down well with an increasingly litigious public, but if doctors keep quiet about misdiagnoses, as may happen now, there is no chance of improving matters. Ideally, autopsies would be carried out on a random sample of people who die. In the US, hospitals once had to have a minimum autopsy rate of 20 per cent, but this was abandoned in 1970. In the UK, the Royal College of Pathologists once considered trying to push for a minimum 10 per cent random autopsy rate, but the Alder Hey scandal kicked the idea into touch. "There would be a substantial outcry," says Benbow.
If one of your family dies and a doctor suggests an autopsy, give permission.
Anatomy of an autopsy
The pathologist first examines the outside of the body. Then they make a large Y-shaped incision from the shoulders to mid-chest and down to the groin. There is almost no bleeding as the heart has stopped beating and there is no blood pressure.
The flesh is pulled back so the doctor can cut away and remove the breastbone and ribs to allow access to the chest cavity. They remove all the major organs, such as the heart and lungs, and many smaller ones such as the thyroid gland, for weighing and further examination. The stomach contents are checked for any drugs or poisons, and many tissue samples are preserved so they can be inspected under the microscope. If the brain needs examining, the pathologist cuts open the scalp from ear to ear and peels back the skin. Then they saw off the top of the skull to remove the brain.
At the end, all the organs except those portions that need to be saved may be returned to the body cavity, and the flesh is sewn up. The scalp incision will be concealed by the pillow when the dead person is in their coffin, so relatives will see no visible reminder of the autopsy.
Based on an article by Clare Wilson
posted by Louis Brothnias @ 1:29 PM
0 Comments:
Post a Comment
<< Home