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Without Autopsies, Hospitals Bury Their Mistakes

Hospital autopsies have become a rarity. As a result, experts say, diagnostic errors are missed, opportunities to improve medical treatment are lost, and health-care statistics are skewed.


Produced by Habiba Nosheen/ProPublica

When Renee Royak-Schaler unexpectedly collapsed and died on May 22, no one ordered an autopsy.

Not the doctors at Howard County General Hospital in Columbia, Md., where the 64-year-old professor and cancer researcher was pronounced dead. 

Not the Maryland Office of the Chief Medical Examiner, which passed on the case because no foul play was involved.

And not Royak-Schaler’s physicians at Johns Hopkins University School of Medicine who had diagnosed cancer in her hip two days beforehand but acknowledged they didn’t know what had caused her unforeseen death.

A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients.

Dr. Jeffrey Schaler addresses family and friends gathered to remember his late wife, Dr. Renee Royak-Schaler. (Jenna Isaacson Pfueller/ ProPublica)

Dr. Jeffrey Schaler addresses family and friends gathered to remember his late wife, Dr. Renee Royak-Schaler. (Jenna Isaacson Pfueller/ ProPublica)

As Royak-Schaler’s husband, Jeffrey Schaler, discovered, even sudden unexpected deaths do not trigger postmortem reviews. Hospitals are not required to offer or perform autopsies. Insurers don’t pay for them. Some facilities and doctors shy away from them, fearing they may reveal malpractice. The downward trend is well-known — it’s been studied for years. 

What has not been appreciated, pathologists and public health officials say, are the far-reaching consequences for U.S. health care of minuscule autopsy rates.

Diagnostic errors, which studies show are common, go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost to learn about the effectiveness of medical treatments and the progression of diseases. Inaccurate information winds up on death certificates, undermining the reliability of crucial health statistics.

It was only because of Royak-Schaler’s connections that her case ended differently. Her colleagues at the University of Maryland School of Medicine urged her husband to authorize an autopsy and volunteered to conduct it for free. 

Friends and family of Dr. Renee Royak-Schaler attend a memorial service in her honor at Westminster Hall on the University of Maryland School of Medicine campus where she worked. (Jenna Isaacson Pfueller/ ProPublica)

Friends and family of Dr. Renee Royak-Schaler attend a memorial service in her honor at Westminster Hall on the University of Maryland School of Medicine campus where she worked. (Jenna Isaacson Pfueller/ ProPublica)

In her case, as in so many, the autopsy revealed a surprise: Royak-Schaler, the renowned cancer researcher, had cancer ravaging her body — in her lungs, kidneys, abdomen and the marrow of her bones. A blood clot, likely related to the tumors, caused her sudden death.

Jeffrey Schaler has wrestled with anger that his wife wasn’t diagnosed sooner but said knowing how she died was better than not.

“There’s a sense of peace that accompanies that knowledge,” he said.

For the last year, ProPublica, PBS “Frontline” and NPR have probed America’s deeply flawed system of death investigation, focusing primarily on forensic autopsies, which are conducted by coroners’ offices and medical examiners when there is suspicion of an unnatural death. State laws vary, but the preponderance of deaths that occur in hospitals are considered natural. When deaths are unexplained, unobserved or within 24 hours of admission, hospitals may be required to report them to local coroners or medical examiners, but such  agencies rarely take hospital cases.

Hospital physicians, with consent from patients’ next of kin, may order a clinical autopsy to explore the disease process in the body and determine the cause of death. That was the norm 50 years ago, when the value of the autopsy was considered self-evident.

“Much of what we know about medicine comes from the autopsy,” said Dr. Stephen Cina, chairman of the forensic pathology committee for the College of American Pathologists. “You really can’t say for sure what went on or didn’t go on without the autopsy as a quality assurance tool.”

Yet, autopsy rates at teaching hospitals, which are typically run on a nonprofit basis and have an educational mission, hover around 20 percent today. At private and community hospitals, which constitute 80 percent of facilities nationwide, rates can be close to zero.

“I know new hospitals are being built these days without a place to do an autopsy,” said Dr. Dean Havlik, the Mesa County, Colo., coroner, who estimated that the overall hospital autopsy rate in his area is less than 1 percent.

Hospitals have powerful financial incentives to avoid autopsies. An autopsy costs about $1,275, according to a survey of hospitals in eight states. But Medicare and private insurers don’t pay for them directly, typically limiting reimbursement to procedures used to diagnose and treat the living. Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, increasing the incentive to skip them, said Dr. John Sinard, director of autopsy service for the Yale University School of Medicine.

“The hospital is going to get the money whether they do the autopsy or not, so the autopsy just becomes an expense,” Sinard said. 

Since a 1971 decision by The Joint Commission, which accredits health-care facilities, hospitals haven’t had to conduct autopsies to remain in good standing. The commission had mandated autopsy rates of 20 percent for community hospitals and 25 percent for teaching facilities, but dropped the requirement. Many hospitals were performing autopsies “simply to meet the numbers” and not to improve quality, said Dr. Paul Schyve, the commission’s senior adviser of health-care improvement. 

Doctors, too, have gravitated away from autopsies because of growing confidence in modern diagnostic tools such as CT scans and MRIs, which can identify ailments while patients are still alive.

Still, in study after study, autopsies have revealed that doctors make a high rate of diagnostic errors even with increasingly sophisticated imaging equipment.

A 2002 review of academic studies by the federal Agency for Healthcare Research and Quality found that when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in one of four cases. In one of 10 cases, the error appeared severe enough to have led to the patient’s death.

“Clinicians have compelling reasons to request autopsies far more often than currently occurs,” the agency concluded.

Schyve called the findings of such studies flawed because cases in which autopsies are performed are typically the most complex, making diagnostic errors more likely. The overall error rate is far lower, he said.

But Sinard said so few autopsies are being conducted — one survey found that 63 percent of hospitals in Louisiana performed none in a given year — that doctors and hospitals can’t say for certain how patients are dying. “They’ve never checked,” the Yale pathologist said.

Pathologists interviewed by ProPublica said they often find diagnostic errors. “We often identify things that the imaging study could not,” said Dr. Debra Kearney, director of autopsy pathology at Texas Children’s Hospital. 

Autopsies can also be a crucial tool for evaluating and improving medical care.

Dr. Elizabeth Burton, deputy director of the pathology department at Johns Hopkins University School of Medicine, said performing autopsies on patients who have died of hospital-acquired infections helps save others. Infection clusters “go in waves” in hospitals, she said. Physicians have used her findings to change antibiotic regimens, snuffing out the bacterium.

Dr. Renu Virmani, president and medical director of the nonprofit CVPath Institute, has used postmortem examinations to help reform the treatment of heart disease. Virmani and her team have collected about 250 specimens of metal stents removed at autopsy from patients who had procedures to clear blockages from their arteries.

Dr. Renu Virmani, a pathologist, in her lab in Gaithersburg, Maryland. With the use of autopsies, her research helped change the way patients with certain heart conditions are treated in America. Dr. Virmani says she finds the low rates of autopsies done on patients who die in a hospital to be alarming. (Habiba Nosheen/ProPublica)

Dr. Renu Virmani, a pathologist, in her lab in Gaithersburg, Maryland. With the use of autopsies, her research helped change the way patients with certain heart conditions are treated in America. Dr. Virmani says she finds the low rates of autopsies done on patients who die in a hospital to be alarming. (Habiba Nosheen/ProPublica)

Their work showed that, in certain patients, a type of stent designed to reduce the risk of blood clots was causing delayed healing, inflammation and reactions that could be fatal. As a result, patients who receive these stents are now required to take blood-thinning medication for a year after the procedure.

Sitting in her lab in Gaithersburg, Md., Virmani peers through a microscope at a specimen slide taken from a 61-year-old man who died suddenly in 2004, about four months after receiving a clot-resistant stent. She points out signs of inflammation in the cross-section of his stented artery, describing the swirls and grains, stained pink and purple so they stand out on the slide. The autopsy showed that the stent had led to the patient’s fatal blood clot.

Autopsies should be used to evaluate the effectiveness of other therapies, Virmani said, from chemotherapy to heart-valve replacements. “The only way to learn is through autopsies.”

Hospital autopsies are even rarer when patients older than 60 die in hospitals, representing a lost opportunity to learn about age-related diseases, Burton said. More than 684,000 such patients died in hospitals in 2008 — more than one-quarter of the total deaths in the country — and just 2.3 percent were autopsied, CDC data show.

Without autopsies to confirm patients’ precise causes of death, public health officials say, the health-care system overall suffers. Erroneous information sometimes ends up on death certificates. Broad categories of disease such as cancer are probably accurate, but specifics such as the type of cancer may not be, said Robert Anderson, chief of the mortality statistics branch of the CDC’s National Center for Health Statistics.

“These data are used to set public health priorities, to develop public health programs and allocate resources,” Anderson said. “We do the best that we can given the information we have, but if you put bad information into the system, you’re going to get bad information out.”

In 1999, the Medicare Payment Advisory Commission, or MedPAC, which advises Congress about Medicare, issued a report stating that increasing the rate of clinical autopsies could improve health care and reduce errors.

The report recommended paying pathologists directly for autopsies and giving hospitals bonuses or penalties for hitting or missing target autopsy rates. The advisory group also suggested that Medicare change its hospital regulations to encourage more autopsies and use them as a standard of performance.

But Medicare has not acted upon these recommendations. An official from the Centers for Medicare & Medicaid Services declined ProPublica’s request for an interview, saying the use of autopsies in hospitals “is not within [Medicare’s] bailiwick at all.”

Other organizations that advocate for better medicine, such as the Institute for Healthcare Improvement, National Quality Forum and The Joint Commission, have not pushed for higher levels of autopsies, either, despite the widely held belief  that this could produce improved care. 

Raising the rate “is not one of our priorities by any means,” The Joint Commission's Schyve said.

Dr. George Lundberg, a pathologist and one of the country’s most vocal advocates for increasing the autopsy rate, shakes his head when discussing the medical industry’s apathy about low autopsy rates.  Lundberg, the editor of the journal MedPage Today, said The Joint Commission should re-establish mandatory autopsy rates “like they used to have back in the good old days of quality when we weren’t running away from trying to find the truth [about] our sickest patients.”

One way to shake the complacency, various experts told ProPublica, would be for insurance companies and the government to pay for autopsies. But an official from UnitedHealth Group, the largest health-insurance company in the country, said the autopsy is not reimbursed because it “isn’t a procedure that would prevent or treat a sickness or injury” in a patient.

Virmani called this shortsighted. The cost of an autopsy is small relative to the money spent on drugs, treatment and diagnostic imaging, she said, and the payoff could save lives and money.

“We are letting go of something which we could really use tomorrow to improve the health care of patients,” she said.

When I was an Internal Medicine resident in the early 1980’s, we were routinely expected to ask families for autopsies, especially in situations of sudden death. The trickiness was determining when to get the medical examiner involved.

As mentioned, cause of death would be verified, improving public health records. But incidental findings (for example, unrecognized cancer) could be important for family history.

If the rate is 20% in academic institutions now, I would be very interested to know how these rates have declined in the last few decades.

For families who are concerned that their loved one’s care was compromised, this is deeply disturbing. It is not in the hospital’s best interests to recommend an autopsy. I hope that there are no out-of-pocket costs for an autopsy.

ProPublica’s “Dollars for Docs” shows the willingness of doctors to unnecessarily prescribe medications that kill or injure more than a million Americans annually.  If those injuries and deaths were treated as criminal assaults, I expect the number of homicides to skyrocket in the US. 

Unfortunately, local, state and federal law enforcement are as reluctant as the reckless docs who accept pharmaceutical kickbacks.  If Hezbollah and al Qaeda injured and killed this many Americans each year, the President and Congress would declare war.  Unfortunately, companies like GlaxoSmithKline and Ely Lilly fund many of their political campaigns.

Clark Baker, OMSJ
LAPD (ret)

Why would hospitals encourage autopsies when so many might reveal malpractice (failure to diagnosis and treat), overtreatment or hospital acquired infections as the cause of death?

As Mr. Baker points out, with so much political campaign funding coming from the medical community big guns (pharmaceutical, insurance and professional organizations like AMA), why would our elected officials even broach the subject?

The documentary “Hot Coffee” aptly describes how widely even our judicial system is being compromised by these same influences.

As a U.S. citizen who became disabled unnecessarily due to medical error with no money to pursue recourse for actual damages or suffering, I no longer believe we have any consumer protections.

Walter D. Shutter, Jr.

Dec. 16, 2011, 6 a.m.

As I see it, there are Three good reasons why we don’t perform more autopsies:  The first reason was mentioned in the story; that since 1971 hospitals no longer are reguired to maintain a 20% autopsy rate to keep their accreditation.  The second reason, also mentioned in the story, is that insurance companies do not pay for the procedure.  The third reason, which was not mentioned, is that autopsy results may cost hospitals and doctors(and their malpractice insurance carriers) big bucks if the results provide evidence of medical errors.

In the immortal words of Deep Throat,“Follow the Money.”

The situation in the US is alarming, because causes of death are a scientific information very useful to drug manufacturers; M.D.‘s and hospital ( “is Dr.X more often than Dr.Y mentioned in causes of death from a similar pathology”?)
What about the situation in EUROPE?

At our medical center, and on our medical service, we actively seek ways to detect unsafe conditions and errors, so that we can improve care. When we find errors, we discuss them in open forums, so that what we learn about improving the quality of care can be spread to all parts of our service, and our hospital. 

When a patient dies and we are able to obtain an autopsy, we always learn something that can improve the care of the next patient.  We regularly urge our residents and staff physicians to seek autopsies, and they do seek them frequently; too often they are refused by next of kin.  Increasing the frequency of autopsies will require that we change public attitudes about them, and make it clear that what we learn from autopsies helps improve patient care.

How are you possibly going to maintain the fiction that you’re “the best medical system in the world” - and so worth every penny of the highest medical costs in the world - if you go around letting people accumulate autopsy evidence that disputes it?

There is something about that phrase “autopsy results” that adds a certain emphasis to a statement disputing that fiction, I might add.

Emily O'Rourke, M.D., Stephen A. Geller, M.D.

Dec. 16, 2011, 2:27 p.m.

Malpractice issues may not be as important as is generally supposed. In general, medicine is practiced at a high level and actual malpractice judgements based on autopsy information are exceedingly unusual. The opposite situation may pertain: juries may decide against a physician whose patient has died on the assumption that “he/she buried the mistakes” by not having an autopsy performed.
  There are other significant reasons for the decline in the utilization of this highly valuable, always instructive, inexpensive method for studying death and, equally important, for studying the pathophysiology of disease and the efficacy and effects of treatments and procedures:
1. Physicians have placed so much trust in modern, highly expensive, not completely reliable imaging methods such as MRI that they no longer recognize the possibility of significant diagnostic discrepancies which still occur in as many as 10-20% of people who die in hospitals.
2. The discipline of Pathology has been significantly de-emphasized in medical education and many medical students and young physicians have never even witnessed an autopsy.
3. In today’s highly specialized medical practice world there may not be a physician with whom the patient’s family can identify as “the” physician, and they may not be comfortable with a relatively impersonal request for permission to perform an autopsy.
4. Department leaders at academic centers, particularly those in internal medicine as well as pathology, who are engaged in administrative or research activities, have little or no interest in the autopsy. In our own institution neither the chair of the medicine department nor the chair of the pathology department have attended autopsy conferences.
5. Most pathologists have little interest in the autopsy. It is a time-consuming, intellectually demanding, sometimes physically difficult activity that is not remunerated and not appreciated. The busy pathologist must tend to other demanding activities such as surgical pathology, cytopathology and clinical laboratory testing where he/she handles a large volume of cases. Many hospitals in the United States no longer have a facility in which to perform autopsies.
6. Public education about the usefulness of the autopsy, including the considerable value to surviving family and friends in terms of their healing through knowledge of the actual events of illness and death, is almost nonexistent. Autopsy is not a topic discussed on talk shows. The major pathology organizations have not committed significant money or effort to public education. Hence survivors are concerned about possible mutilation to the body (which does not occur), possible delays in burial (which are not necessary) and possible expense (which does not pertain in teaching hospitals). The physician with whom the survivor interacts is generally uninformed about these matters.
7. Perhaps most alarming is the fact that most young pathologists do not know how to perform an autopsy well. Their teachers are usually not interested and may themselves be inexperienced and, without the benefit of something like a regional autopsy center, they have almost no experience.

One of the solutions, mentioned in the article, is to establish regional autopsy centers where pathologists interested in the autopsy as a scientific discipline can practice and continue to learn, where autopsy can appropriately function as a distinct specialty in and of itself with opportunities for ongoing research, and where costs to the health system can be minimized.

Emily O’Rourke, M.D.
Stephen A. Geller, M.D.

Department of Pathology and Laboratory Medicine
Cedars-Sinai Medical Center
Los Angeles

Wow…very pedagogic way to poo-poo not just autopsies but pathologists and their current practices.

Guess they’ll have to throw out all murder convictions based in part or entirely upon pathology reports.

George Krzymowski, M.D.

Dec. 16, 2011, 4:15 p.m.

Continuing to perpetrate the many fictions associated with the autopsy and its supposed value is of no use to anyone.  If there was anyplace that evidence based medicine is lacking it is the autopsy.  Cutting up the dead to reveal their secrets has been romanticized by television, film, journalists and salaried academic pathologist alike.  I’ve had to listen to Dr. George Lundberg pining for “the good old days” for 25 years.  Enough already!

Drs. O’Rourke and Geller continue this nonsense.

1.  Can the autopsy be an “inexpensive method for studying death” and simultaneously “a time-consuming, intellectually demanding, sometimes physically difficult activity”.  Really?  The truth is that they are an EXPENSIVE, time-consuming, intellectually demanding, sometimes physically difficult activity.

2.  There is a reason “Department leaders at academic centers, particularly those in internal medicine as well as pathology, who are engaged in administrative or research activities, have little or no interest in the autopsy.”  Show me the significant medical advances from the last 50 years that derived their data principally from autopsy based studies.  It’s slim pickings.  Autopsy studies, even the best ones are virtually all retrospective studies and subject to all the problem and biases of retrospective studies in other areas of medicine.  If you are serious about the autopsy and not just blowing wind, show me your rejected grant application for a prospective autopsy study. $100 bucks says you can’t.

3.  The abuse of patient families at a time of great emotional vulnerability that occurred prior to 1971 is conveniently overlooked.  A hospital chaplain who routinely brought chaplaincy trainees to the morgue at a 900 bed training hospital told me that a substantial amount of his time in the pre 1971 era was spent counseling families who regretted giving consent to an autopsy because they though they “had to”.

3.  The idea that physicians are hiding malpractice is just foolish nonsense.  In over 500 autopsies over 20 years as a community pathologist and medical examiner I can confidently say the number of cases of previously undocumented medical malpractice is vanishingly small.  Exculpatory evidence is far more often the case.  Unexpected significant medical finding are also rare and close reading of most autopsy studies bears this out.

4.  Oh and by the way Mr. Allen, only a medical examiner can “order an autopsy”, and then only under the specified statutory guidelines.  The clinical doctors at Howard County General Hospital might have requested an autopsy consultation from their pathologist.  When journalists and clinicians by their language treat pathologist as peons rather than professionals, its hardly a surprise that “most pathologists have little interest in the autopsy”.

I could go on and on, but I’m on my dime.

Anna Gardiner

Dec. 16, 2011, 4:29 p.m.

I agree in part with Dr. Krzymowski that autopsies are not necessarily effective in identifying the cause of death. For instance, my mom had cancer but the autopsy my sister insisted upon said she died of kidney failure.

Another friend went to the hospital ER and shortly thereafter ended up in a coma. The cause of death on the autopsy: She stopped breathing. I’m not kidding.

Having trained as a clinical chaplain, I see a few things lacking in the article and in the comments:

1) How does an autopsy interact with a family’s grieving process?

2) How do changing views of death, soul, body, and spirituality in the US interact with a family’s choice of whether to do an autopsy?

2) Relatedly, how does the decline of autopsies correspond to the increased emphasis within those same decades on the rights of patients and their families to ask for the care they want and decline the care they don’t want? (This gets into the question of public education on the usefulness of autopsies that Drs. Geller and O’Rourke raised.)

Philip Branton MD FCAP

Dec. 16, 2011, 7:37 p.m.

I was in private practice as a pathologist for 14 years.  A major reason autopsies are not done in the private sector is: they are a loss leader.  As alluded to above, no one wants to pay the pathologist for his or her professional time.  Autopsies are difficult to perform, physically demanding (especially if the patient is obese), and time consuming.  And if the patient is HIV + or has hepatitis, they are not without risk to the pathologist.  Small wonder most pathologists would rather be in their offices signing out cases which provide remuneration.  When families request an autopsy, the pathologist additionally fears litigation—not necessarily being sued personally, but being subpoened, dealing with depositions, time in court—all in an era when hospital pathology departments, like every place else, are down-sizing.  Time away from the lab means either more work for the partners, or late nights after a day or two in court.  Who can blame the pathologists for not wanting to spend time in the mogue any more?  It is sad, because, as Dr Lundberg correctly notes, much can still be learned in the morgue. Clinical diagnoses are sometimes wrong—not because of malpractice, but because there is still much doctors do not know, in spite of advanced imaging technologies.  Radiologists are not quite ready to replace pathologists completely.

  I completely agree with George Lundberg and Renu Vermani (both mentors of mine in the now increasingly distant past…).  Unfortunately, as with government, the American public gets the health care system it wants to pay for, or maybe it deserves.  If insurance companies heard from enough of their clients that autopsies should be a covered benefit, they might reconsider.  If the Joint Commission thought it was important, things might change.  If our Congressmen thought it was important, things might change.  Few of them even know what pathologists do, let alone have interest in the ins and out of autopsy pathology. But until there is a collective societal agreement that this is important, nothing will happen, alas.

Ian R Lawson, MD

Dec. 16, 2011, 9:03 p.m.

Strong agreement with Drs. O’Rourke and Geller and their reasons for why autopsies are not performed.
In my geriatric practice, I invariably requested autopsies on my patients, giving the reason to families that “There is one more important thing that your mother/father can give to us and help us by. Nearly always he/she has something more to reveal than what we diagnosed in life. And finding and knowing that keeps us humble.” I rarely had a refusal.
But when I attended my last autopsy of one of my patients, who had been under care of the medical residents, I asked the lone pathologist, “Where are the residents?” They wait for the images, I was told (of pictures on a screen in a comfortable conference room).
This parallels what Verghese wrote about in the NEJM, of the preference for teaching and therefore learning to be conducted away from the patient, alive (or dead!).
cf. that marvellous image of the Bologna medical school autopsy (the physicians being pressured by the law faculty to perform them). The professor is far away from the body; a menial does the crude dissection while physicians maintain a ‘no-contact’ observation. And read Charles Singer’s comment!
So, after decades of involvement, I see us as being undone by our confidence in images and abstractions, away from the flesh. And don’t blame the (quite marvellous) technology for this regression in the manner of our observing. Medicine has always preferred a practice of some distancing, shall we say, in its conduct towards the sick. Rare have been the Pares and Vesaliuses.
And not by the way, conducting autopsies as fault-finding (except for forensic reasons) is not the principal reason.

people have to die. why does data?

The comments make disheartening reading; they describe a medical community evolving away from being “hands on” physicians and into self-distancing technicians.  That doesn’t bode well for patient care - whether you’re alive, or dead.

And it certainly hasn’t shown any efficacy at controlling costs.

“plus ça change, plus c’est la même chose”  (The more things change the more they stay the same). - Jean Baptiste Alphonse Karr - 1808 - 1890.

At the end of WWII I attended a lecture on statistics in London by a world renowned epidemiologist.  One of the things he told us was:  “If you can’t find anything wrong with a patient - dead or alive - and learn from it then you haven’t looked long or hard enough.”

There is no honesty in medicine anymore.  It’s all above covering up the truth and ordering the most profitable treatments and drugs while patients are alive so why would they want an autopsy.  Even pathologists have been trained to be willfully ignorant.  It’s the paradigm of the medical industrial complex that is the problem.  We don’t want to know that mercury poisoning kills, pesticides kill, that GMOs kill, that gadolinium based contrasting agents kill and that radiation kills.  The results of autopsies don’t tell us anything.  This one died of cancer so what, what caused the cancer in the first place?  Those are questions we need answers to but they are not forthcoming.  And I blame the doctors for not being honest and bringing attention to what are the true causes of illness and death. 
Can any of the doctors that posted here tell us why we don’t yet know what causes autism, RA, MS, Lupus, CFIDS, FM, scleroderma or cancer?  I think it’s because someone is liable for these diseases and rather than admit the truth or look for the likely culprit you stick your head in the sand and spew meaningless academic explanations about nothing.  In my opinion you are a useless profession.  The country would be better off if we didn’t have doctors at all for all the good you do today.  There are a few good ones left and but even they have been silenced.

I agree with Dr. Branton, that you get what you pay for. The pathologists in my hospital are happy to perform an autopsy… as long as they are paid in full up front. Billing the patient is of course problematic. This naturally, is where any further discussion from the interested party ceases. Behind the indignation here at “pro publica” is the implication that this information should be “pro bono”.

You’re wrong Sud, my indignation comes from being poisoned by doctors and PhRMA but by all means keep blaming the victims of the medical industrial complex and stay safe in your little bubble.  This model/bubble is unsustainable and is the next bubble to burst whether you think it will or not.

Anna Gardiner

Dec. 18, 2011, 2:46 p.m.

This conversation reflects the epitome of what is going on with U.S. healthcare. I speak as one who became unnecessarily disabled at the height of my career at age 50 (several years ago) due an undiagnosed intestinal blockage. I had the necessary surgery this past October thanks to Medicare. Had I not had this surgery, perhaps the problem would have been discovered during an autopsy, but I think not.

What I learned from years of investigating the U.S. medical system in order to get the care I needed was that there are excellent physicians out there with the knowledge and will to help who find a way to get paid within the system.  They are as scarce as hen’s teeth. The way it is now is that Medicare is left picking up the tab on private industry’s failures for those astute and stubborn enough to find that elusive physician.

Rita G., Family Nurse Practitioner, NJ

Dec. 18, 2011, 6:45 p.m.

When my close relative passed away few years back, biggest hurdle and reluctance to grant permission to do autopsy was from immediate family members as they didn’t want to see the mutilated body of our relative during Wake Ceremony.

The fact is that after even after autopsy the body can be sewn back to almost perfect state without any visible mark of dissects.

I am impressed by Dr. Virmani and her staff for pioneering the effort for doing autopsies in hospitals. As a practicing NP, I do suggest the grieving families for autopsy of their lost relative in order to predict and diagnose their disease.

I would like a sticker I can put on my license next to my organ donor sticker stating that upon my death I insist on being autopsied, no matter how I died.

Mark Metzdorff MD

Dec. 21, 2011, 3:20 p.m.

I think you picked a bad example to try to make your point.  With condolences to Dr. Schaler on the loss of his wife, I find it a little hard to believe that, having found a bone metastasis, her Hopkins doctors wouldn’t have known that she had cancer in other areas of her body.  The first test ordered after such a finding would be a head-to-toe CT scan or PET/CT scan which would have revealed the same findings as the autopsy.  Sudden death in such a patient is almost always due to pulmonary embolism—again a piece of knowledge that doesn’t require an autopsy.  Unfortunately, knowing these facts wouldn’t likely change the treatment, or the poor prognosis of such a patient.

I’m sure that Sharon is frustrated at the slow pace of medical discovery in some areas. However, it is unfair to point out only conditions wherein the causes are not yet known and to indict the entire medical/scientific profession for lack of trying (not to mention greed). Rigorous medical science and discovery take time. One can point to many conditions where causes have been discovered. For example, scientists very quickly found that HIV is the cause of AIDS. Finding the viruses causing measles, mumps, rubella, and polio and the bacteria underlying diphtheria, meningitis, and other diseases has led to effective vaccines. Discovering the intricacies of bacterial metabolism has led to effective antibiotics. The cholesterol hypothesis of heart disease has resulted in drugs that can help prevent coronary artery disease. The underlying mechanisms leading to various cancers has made some of them treatable (eg., HER2-positive breast cancer, chronic myelogenous leukemia) or even curable (eg, Hodgkin disease). Epidemiological and metabolic studies have revealed lifestyle as a major factor in disease prevention. I suggest Sharon give adequate acknowledgment to what has already been accomplished and that with adequate funding and continuing education of clinicians and scientists that such progress and more will occur in the future.

I counsel for a reasonable balance ...

As a pathologist, having to do an autopsy on an HIV/Hep. C infected patient to give the family no new information about why the patient died and, realistically, not change anything in clinical practice represents a waste of time, a waste of resources, and an unfair risk of myself contracting a devastating disease

I look at autopsies as a test.  With any test, we evaluate sensitivity and specificity with regard to its result.  We don’t just order medical tests at whim because we want to utilize resources (e.g. time, money, man-power) effectively.  If the utility of a test overall does not outweigh its cost, then we don’t perform it.  The lay-public wants every test ordered, and they feel cheated if everything hasn’t been ordered. 

But that’s not how medicine is supposed to work.  So, autopsies on patients with HIV/Hep. C?  Autopsies on patients with clear clinical evidence of an myocardial infarction?  Autopsies on patients with clear clinical evidence of metastatic cancer?  What’s the point?  We have already learned about these processes, and I encourage anyone to pick up a pathology textbook as proof. 

The only autopsies that are worth doing are:
— Surgical or other iatrogenic mortality
— Sudden cause of death in an otherwise healthy person (especially child)
— Reason to suspect a genetic disorder which may affect family members

Even in these instances, autopsies should be restricted in what organs are examined (rather than cutting out all the organs and the brain when the chances of finding anything RELEVANT are remote). 

We don’t (at least shouldn’t) CT scan everyone when they are alive.  Why should we do the physical equivalent in someone who is dead?

I counsel for a reasonable balance ...

As a pathologist, having to do an autopsy on an HIV/Hep. C infected patient to give the family no new information about why the patient died and, realistically, not change anything in clinical practice represents a waste of time, a waste of resources, and an unfair risk of myself contracting a devastating disease

I look at autopsies as a test.  With any test, we evaluate sensitivity and specificity with regard to its result.  We don’t just order medical tests at whim because we want to utilize resources (e.g. time, money, man-power) effectively.  If the utility of a test overall is not clinically indicated or does not outweigh its cost, then we don’t perform it.  The lay-public wants every test ordered, and they feel cheated if everything hasn’t been ordered. 

But that’s not how medicine is supposed to work.  So, autopsies on patients with HIV/Hep. C?  Autopsies on patients with clear clinical evidence of an myocardial infarction?  Autopsies on patients with clear clinical evidence of metastatic cancer?  What’s the point?  We have already learned about these processes, and I encourage anyone to pick up a pathology textbook as proof. 

The only autopsies that are worth doing are:
— Surgical or other iatrogenic mortality
— Sudden cause of death in an otherwise healthy person (especially child)
— Reason to suspect a genetic disorder which may affect family members

Even in these instances, autopsies should be restricted in what organs are examined (rather than cutting out all the organs and the brain when the chances of finding anything RELEVANT are remote). 

We don’t (at least shouldn’t) CT scan everyone when they are alive.  Why should we do the physical equivalent in someone who is dead?

Ed Uthman, MD

Dec. 22, 2011, 2:43 p.m.

I am a board-certified pathologist with a combined 30 years practice experience. Apologias for autopsies have cropped up again and again over my career. What I have never seen, though, is any evidence that the autopsy really is the “gold standard” in medical diagnosis. It is clearly very good for making some diagnoses (bullet wound to the heart, pulmonary thromboembolism) but next to worthless for making others (death by poisoning, arrhythmias, early myocardial infarcts, hemodynamics disturbances [such as shock], and sepsis, to name a few). The fact that the autopsy has enjoyed such an exalted status has provided undue license to autopsy pathologists, especially forensic pathologists, to elevate their wild speculation on cause of death to ultimate finality. In the era of excellent medical imaging and clinical laboratory tests, we need to relegate the autopsy to the level of that of one of many diagnostic tools that can be used or misused, depending on the skill of the physician who uses it.

Mark Thompson

Dec. 23, 2011, 2:33 p.m.

Excellent job at not letting actual facts get in the way of a good narrative, Marshall.

Janiece Staton Retired RN, BSN, MSW, MAT

Dec. 28, 2011, 6:56 a.m.

As a now disabled (thus forcibly retired) RN, BSN, clinical MSW, & MAT-educated teacher, I am SO GRATEFUL for your work!  You keep focusing on topics that other media will NOT investigate, such as the amount of deaths being caused by indifferent, incompetent, unethical, irresponsible health care systems, groups, & individuals, across the USA! 

In my 25+ years practicing as a clinical RN, BSN, the amount of malpractice I personally witnessed, let alone saw documented in one patient chart after another, HORRIFIED ME!  I had no way of knowing, that the same disastrous health care system (which has run amok in Oregon, since the late 1980’s), would lead to me becoming severely & permanently disabled, myself six years ago. 

There are several MAJOR changes that MUST be made to the USA’s current health care system, IMHO, if ANYONE here is to consistently receive quality health care.  The first involves regular (at least every 5 years) ongoing re-licensure testing (theoretical & “hands-on”), for all licensed/certified health care providers (of ANY type).

It’s MUCH too easy, for currently licensed health care providers to ignored, overlook, and/or pay minimal attention to issues of lifelong continuing education.  I’m capable of & have been actively engaging in “medical (MD) continuing education” opportunities.  It’s such a laughably simple process, it makes me NAUSEOUS!

Most of their “continuing education articles” require them to only answer TWO questions, after skimming through the article.  They are free to answer those TWO questions, as many times as they wish, UNTIL they answer 70% or higher on the “test questions”!  All this, while they’re, simultaneously, allowed to re-read the same article, over & over, until they get the TWO questions CORRECT!

In my professional experience, most elementary students could pass any “test” like THAT!  Yet we wonder why our nation’s health care system costs SO MUCH & gives such poor results.  Instating mandatory complete autopsies would so enlighten the general public, (as to all of the health care issues that MDs are ignoring/ignorant of),  I believe the outcry to Washington, D.C. would be deafening!

Right now, nearly the entire focus within our health care system, is on people at the top getting as wealthy as they can, as quickly as they can.  The Scrooge-like attitudes toward patients & the general public, are so blatant (at least here in Oregon!), that RNs have been leaving the profession in DROVES.

Patients are now treated as “disposable goods”, rather than as soul-filled beings.  The health care workers on the “front-lines” (particularly the RNs, PTs, OTs, S/LPs. RTs, CNAs), are expected to pick up ever-enlarging numbers of patients to care for, during the same periods of time, for less money/benefits, & with minimal educational help from their mega-wealthy employers!

I made LESS money, at the end of my RN career, than I did newly out of nursing school in 1984.  My experience is the NORM, within the world of nursing, but most people choose to forget that RNs even exist.  If you doubt this, think back to the hours of 9/11 media coverage that occurred, in 2001. 

Did you witness a SINGLE RN being interviewed by anyone?  No one, typically, recalls EVER seeing RNs anywhere, during that terrible time in our nation’s history.  Yet, I know that RNs are STILL taking care of the survivors of those plane crashes, to this day!  That’s what WE DO.  At the same time, most people do not know that RNs are #2, in the USA, in terms of “on the job” injuries.  We’re so easily ignored/forgotten.

It’s time for licensed professionals to be held responsible for maintaining their CLINICAL credentials.  Otherwise, they need to “retire” their licenses, IMHO.  Clinical credentials need to be repeatedly demonstrated, at least every five years (we have to undergo CPR training, every 1 - 2 years). 

Though the very same “managers” will, undoubtedly, squack LOUDLY about the “costs” involved, I would feel comfortable any time, showing them the “costs” involved, in NOT requiring such ongoing standards!  They have been piling up, all over my home, ever since my 72 year old surgeon butchered me so badly, during a “minor” procedure to remove a kidney stone, that I am now partially paralyzed on my left trunk, have a large “flank bulge” hanging off my left side, am on the brink of requiring kidney dialysis, am in severe/chronic pain, & experiencing other complications.

Thank you for doing your part to bring these major issues to light, Propublica!

This article is part of an ongoing investigation:
Post Mortem

Post Mortem: Death Investigation in America

A year-long investigation into the nation’s 2,300 coroner and medical examiner offices uncovered a deeply dysfunctional system that quite literally buries its mistakes.

The Story So Far

In TV crime dramas and detective novels, every suspicious death is investigated by a highly trained medical professional, equipped with sophisticated 21st century technology.

The reality in America’s morgues is quite different. ProPublica, in collaboration with PBS “Frontline”  and NPR, took an in-depth look at the nation’s 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.

More »

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