NPR and ProPublica yesterday ran a fine story on why we need autopsies – but, alas, do them only rarely. Half a century ago, roughly half of all hospital deaths in the United States got autopsies. These post-mortems corrected tens of thousands of wrong or partial diagnoses, taught doctors and hospitals invaluable lessons (humility among them), and helped revealed both trends in misdiagnosis and new diseases ranging from Legionnaires disease to West Nile virus. The autopsy, as the NPR/Propublica report story put it, is the ultimate medical audit. It is a foundation of modern medicine, and its two greatest values are to show doctors where they tend to go wrong, both on the individual level and through all of medicine, and providing crucial medical information to the families of the dead. It ensures that instead of burying their mistakes, doctors learn from them.
In the NPR/ProPublica story, for instance, an autopsy revealed that an otherwise mysterious death was due to a pulmonary embolism -- and that the embolism was in turn caused by widespread cancer in a woman who was thought healthy. This history of cancer will be of vital importance to her children and other relatives. It will also teach the doctors who cared for her some valuable lessons in diagnosis and treatment.
Unfortunately, the autopsy's decline over the last half-century is not a brand-new story. Medical watchdogs have been howling about it for a couple decades. And seven years ago, I wrote "Buried Answers," a New York Times Magazine feature, that explored at greater length much of the same information that is in the excellent NPR/Propublica story.
Yet I'm glad to see the NPR/ProPublica story; this is a tale that cannot be told too many times. To reinforce the NPR/ProPublica story, I thought it might be useful to run here the last section of my story. It describes a particular autopsy that I attended, its unexpected findings, and their implications, both for the particular patient — who left the room looking every bit as good as he did when he entered — and for those close to him both in his life and in his treatment.
From "Buried Answers," New York Times Magazine, 24 April 2005:
Recently I stood in the autopsy room of a large teaching hospital waiting for a body to be brought up from the morgue. The young pathologist who would be overseeing the autopsy told me what little he knew of the morning's patient. The middle-aged man had come to an emergency room suffering seizures. A CAT scan of his head showed a lesion, possibly a tumor, in his left frontal lobe. He initially refused a biopsy, saying that he might seek a second opinion. The emergency-room doctor, worried about pressure in the patient's skull if the mass expanded, put him on anti-inflammatory steroids and sent him home. Sometime later the man came in again with stronger and more persistent seizures. Despite efforts to ease pressure in his skull, he progressed from seizures to a coma and died. Midmorning the day after that he was on a gurney on his way to the autopsy room. The man was not overweight and had no known history of serious illness. His main compromising factors were that he was an ex-drug user and a smoker. "The drug use would suggest infection," the pathologist said. "The smoking, obviously, cancer."
So what killed him?
"Most likely he herniated," the pathologist said. "Things got too tight in his skull from whatever this growth was, and the pressure builds and finally it pushes the base of the brain down through the opening where the spinal cord enters the skull. That fits with the way he died. But even if that's right, we still don't know what the lesion is." At this point we heard the rumbling of wheels, and the autopsy assistant pushed a gurney covered with a canvas tent into the room. "We'll know more soon," the pathologist said.
He stepped out to get gowned up, and I went in to watch the assistant prepare things. By then the canvas tent was removed to reveal a body wrapped in sheets. The assistant worked efficiently but with a calm, understated respect. With no more force than necessary, he pulled the body from the gurney onto the autopsy table and unwrapped it. The patient appeared to be thinking: his eyes, slightly open, stared dreamily at the ceiling.
In addition to the pathologist, the assistant and a pathology resident, who would do the actual knife work, eight others attended, including a fourth-year medical student, two residents, three neuropathologists and a cardiac pathologist who had just dissected another patient's heart and lingered to see how the brain case played out. As people milled and talked, the assistant sank a scalpel into the flesh behind the man's ear and began cutting a high arc behind the rear crown of the skull. When he reached the other ear, he pulled the scalp's flesh away from the skull a bit, crimped a towel over the front edge of the opening he had made and, using it for grip, pulled the scalp forward over the man's head. When he was done, the man's skull lay completely exposed and his inside-out scalp covered his face down to his mouth. Now a neuropathologist, wielding the skull saw (like a cordless kitchen mixer with a rotary blade), carefully cut a big oval in the rear and top of the man's skull. He then used a hammer and chisel to tap around the seam. Finally he tapped the chisel in at the top of the cut and pried. With a sucking sound the skullcap pulled away.
The brain looked unexpectedly smooth. "That's the swelling," the neuropathologist said. "The convolutions usually show much more plainly." He gently pulled back the frontal lobe and slipped scissors behind the eyes to snip the optical nerves, then the carotid arteries and finally the spinal cord itself. Then he gently removed the brain and set it upside down on a table.
Even my untrained eyes could tell things weren't quite right: the left hemisphere was swollen. The growth in the left frontal lobe, less a lump than a slightly raised oval area about an inch long, was paler, yellower, firmer and more granular than the pinkish-tan tissue surrounding it. "Could be a tumor," the neuropathologist said. "Could be an infection. We'll know more in a few days." Similar lesions were eventually identified on both sides of the brain.
With a pair of scissors, he pointed at a bulbous area around the brain stem. "Here's the herniation. See how it protrudes? That's where it got pushed down through the opening where the spinal cord comes through. That's the medulla that pushed through, which, among other things, controls the heart and breathing. That's just not consistent with life."
He clipped a few samples from the lesion, and with that he was largely done. The assistant, meanwhile, worked on, and with the brain exam finished, the pathologist soon joined him. They extracted meaty lungs and a big liver. Pus oozed out when the trachea was cut. All this suggested systemic infection. "At this point, I'd call it an even toss between infection and tumor," the pathologist said. "If he tests positive for H.I.V., my money goes on infection."
This initial exam of the organs took some 15 minutes. When they finished, the group spent another hour dissecting the organs. The exercise was now more educational than diagnostic, but the pathologist showed no sign of routine-induced boredom; on the contrary, he clearly enjoyed showing the residents the hidden adrenal glands, the chest-wall vessels sometimes used for coronary bypasses and the vagus nerve's lacy, laddered course through the chest.
The full results would take several more days to come in. But they knew by the next day that the patient was H.I.V.-positive, and by the second day that the mass was not cancerous but an infection found mainly in immunocompromised patients like this one.
These findings had multilayered implications. That the man had H.I.V., for instance, would presumably mean something to any of his sexual partners. (Many states require the primary physician to contact sexual partners in such cases.) The rest of his family might find some relief in knowing that there was no tumor and that their own cancer risk was thus not raised. Beyond that, the case's main epidemiological significance was its addition to evidence that infections form an ever-growing but oft-overlooked cause of death -- another small correction in our assessment of what kills us. And that makes for better doctors. "You don't learn these things all at once," the pathologist said. "You learn a lot all at once in med school, sure. But after that, you become a better doctor by learning a little bit at a time. Incremental adjustments. That's what makes us better doctors. And this is the place you learn them better than anywhere else."
When a believer is in the full flush of describing autopsy's gifts, when you witness how quickly and effectively the procedure delivers them, it's easy to think that the autopsy will make a comeback. How could it not? At a time when medicine takes continuous fire regarding errors -- politicians and patient advocates outraged at studies showing that 100,000 Americans die each year from medical errors, tort lawyers chasing mistakes on which to hang huge judgments, malpractice rates jumping at triple-digit rates -- how can medicine ignore an instrument proven to detect error?
Yet it does. Other than hoping for a long shot, like Medicare or the Joint Commission on Accreditation of Healthcare setting autopsy-rate requirements, there is seemingly no quick return to routine autopsies. "We just have to do this one hospital at a time," says Dr. Pat Lento, head of the autopsy service at Mount Sinai in New York. But most hospitals have no plans to revive the autopsy. And while physician organizations like the A.M.A. generally support the autopsy, most doctors don't avail themselves of it. The sad truth is that most of medicine seems to have relegated the post-mortem to a cabinet of archaic tools, as if the body's direct lessons no longer matter. In the end, the autopsy's troubles resemble those in a medical case in which the causes stand clear and a cure stands ready, but the patient doesn't take things seriously enough to pursue the fix.
***
Toward the end of the autopsy I saw of the man who died from an ignored infection, someone asked the assistant if he could really put him back together for a funeral. It was almost 2 p.m. and the man was in pieces. His torso was a big red bowl formed by his back ribs, his skin hung splayed on either side and his scalp was stretched inside-out over his face. The assistant smiled and said, "Oh, sure." The pathologist added: "Absolutely! This guy could go to his wake tonight."
And so it was. Unlike most things, an autopsied body can be put back together far more easily than it can be taken apart. It took less than half an hour to replace the breastplate and sew up the man's torso; if he had a suit, it would fit as before and hide all. The skull cap all but snapped into place. The assistant rolled the man's scalp back over his head and started to suture it up. When he was done, our patient looked pretty good indeed. It was remarkable, actually, after all we had found about what ailed him, that he should still gaze at the ceiling, unchanged and none the wiser.
