Who Killed Autopsies?

What if the airline industry lobbied to end the practice of routinely investigating the cause of each airline crash? After all, if there is no investigation, it will be hard to show an airline was at fault. You might imagine there’d be a public outcry. But in 1970 the US medical profession did essentially the same thing, and few complained:

Today, hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s. … 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. …

In 1998 the Journal of the American Medical Association reported that autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time. … Until 1970, hospitals had to autopsy at least 20 percent of their patients in order to remain accredited. Once that requirement was dropped, autopsy rates began to fall, due to lack of direct funding, fear of litigation and increasing reliance on technology as a diagnostic tool, among other reasons. … Today, about 40 percent of hospitals don’t perform autopsies at all. (more)

The idea that we could afford autopsies before 1970, but now they are too expensive to afford is pretty crazy. In 1970 the US spent 75B$ on medicine (7% of GDP); we now spend 2500B$ (18% of GDP). 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. This can explain doc “fear of litigation”, dislike for autopsies that might disagree with tech diagnoses, and lobbying to cut accreditation rules requiring autopsy funding.

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?

Added 20May: More detail on the transition:

For most of the postwar period up to 1970, hospitals generally paid it, essentially because they had to: the Joint Commission on Accreditation of Healthcare Organizations required hospitals to maintain autopsy rates of at least 20 percent (25 percent for teaching hospitals), which, then and now, is the rate most advocates say is the minimum for monitoring diagnostic and hospital error. The commission eliminated that requirement in 1970. Lundberg says that this happened because hospitals, which had already allowed the rate to drop to close to 20 percent since its 1950’s high of about 50 percent, wanted to let it drop further and pressured the commission. The commission’s current president, Dr. Dennis S. O’Leary, says it eliminated the standard because too many hospitals were doing poor autopsies — and often only the cheapest, simplest ones — just to make the quota. (more)

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  • http://www.jasoncollins.org Jason Collins

    I am not convinced this is clear evidence. What is the willingness to pay of the relatives of the deceased? Is there evidence of unmet demand (that is, demand which people are willing to pay for)? Is there evidence that the level of autopsies conducted before the 1970s was delivering benefits in excess of the costs? The single example given in the article suggested the autopsy was a waste of time.

    • Tiferet

      Jason, why on earth should the family have to pay? This is data the public and the hospital should be paying for. The public, because we need to know why people die in hospitals–both people who seem unlikely to die, because something is wrong if they do, and people who don’t, because sometimes the very disabled or elderly are subject to criminal action that perps know they’ll get away with because we expect them to die. And the hospital, so they know how well they are doing and what they are getting wrong.

      • John

        … and hospitals get their money from patients. So either only the patients who die pay or all the patients pay. Or taxpayers could pay, I suppose, which would be all patients of every injury or disease every. But at that point you may as well go to a single-payer medical system.

  • http://huntgatherlove.com Melissa

    They also provide important data for studies of human health and variation…

  • http://praguestepchild.blogspot.com/ Sean

    More an example of wanting to cover one’s ass. That doesn’t preclude doctor’s from thinking they’d done everything humanly possible, or that they’d made an “honest” mistake that doesn’t deserve to be drug into the court system, etc.

  • http://www.emedconcepts.com Steven Davidson

    I’m a physician who went to medical school 1971-75 and recalls the autopsy lab well from that time.

    Other parties beyond physicians played a big role in the decline of the autopsy, not least the payment for services that used to be “free” especially in large urban teaching hospitals.

    Beginning in 1965 with Medicare and state Medicaid programs patients started receiving services as “paying patients” and no longer as “charity patients.” Consequently, both families of deceased patients and the hospital and physicians caring for these patients altered their behavior around asking for and granting permission for autopsy. I can’t recall the citations, but there’s peer-reviewed research around this.

    Some physicians are venal. So are some economists, bloggers, commentators and people generally.

    Regards./Steve

    • http://www.uweb.ucsb.edu/~criedel/ Jess Riedel

      This seems like an incredibly superficial treatment of this situation.

      My second-hand understanding is that autopsies used to be covered by the health insurance of the deceased in almost all cases as a matter of good faith on the part of the insurance company. But now most insurance companies refuse to pay for them except in specific circumstances. (Someone correct me if I am wrong here.)

      My father, a physician, has expressed a desire for the opportunity for more autopsies in cases where the cause of death isn’t clear. But the insurance company won’t pay for them and the hospital won’t pay for them (why would they?), so it would come out of his own pocket.

      This seems a simple problem of funding. The benefits of autopsies are communal (better understanding of diseases), but the costs (both n terms of money, and possibility of lawsuits) are currently local. Yes, perhaps doctors aren’t banging down the doors of congress to get funding for things that can only hurt them, but this hardly qualifies as a concerted effort to cover up wrong doing.

      Robin, you make a serious allegation when you say

      What if the airline industry lobbied to end the practice of routinely investigating the cause of each airline crash? …in 1970 the US medical profession did essentially the same thing, and few complained

      Where is the evidence that doctors are campaigning against autopsies?

      • http://www.emedconcepts.com Steven Davidson

        Excellent. That’s exactly the case in the six hospitals where I’ve worked since 1975–all teaching hospitals, all seeking more autopsies through training of staff on how to solicit them, all budget constrained in a world of unlimited wants and limited means.

        @Jess–no offense taken, I recognized immediately you were commenting on the initial article. I deliberately kept my response short and focused on a macro economic issue as this is an economist’s site.

      • Worshack

        This seems a simple problem of funding.

        Taken individually, aren’t all problems of funding “simple”? It’s in the aggregate that they get somewhat more complex.

    • http://www.uweb.ucsb.edu/~criedel/ Jess Riedel

      Sorry, Steven, I miss-clicked. My comment was supposed to be a general comment on the post, not a reply to your comment (which I found useful) in particular.

  • Sigivald

    <I.The idea that we could afford autopsies before 1970, but now they are too expensive to afford is pretty crazy. In 1970 the US spent 75B$ on medicine (7% of GDP); we now spend 2500B$ (18% of GDP).

    Who’s this “we”, bwana?

    I’m amazed you fell into that trap – there is no generalized “we” that spends an undifferentiated pot of money on medicine (healthcare, more accurately).

    Individuals spend lots of that money directly; much more is spent on their behalf by insurers.

    But who pays for autopsies?

    Insurers, only if they think malpractice is likely enough that they could recover costs in a lawsuit. Likewise, families. Sometimes, I believe, the State, if there’s evidence of foul play, to aid in possible prosecution.

    Research autopsy funding has no obvious relation to “medicine” spending at all; the only relation I can see is that both happen at hospitals and involve doctors.

    (Now, yes, a renewed mandate of more autopsies to stay accredited is “affordable” in that prices could certainly be raised a bit to cover it – though perhaps if Health Care “Reform” is not repealed that will change – but it’s unclear that that would be of any significant use, or worth the increased costs to consumers.)

    • Scott H.

      I agree 100% but have one more thing to add.

      Robin,

      In regard to your 7% versus 18% argument. The logic goes the opposite way. If my gas budget went from 7% total income in 1970 to 18% in 2011, you can be sure that I would be watching and eliminating my car trips much more in 2011 than I was in 1970.

  • http://walledvillage.blogspot.com/ Shangwen

    Autopsies declined in Canada and the UK as well, both countries with lower rates of litigation and different cost structures. We rarely do them in the hospital network I work in either (in Canada), and families that do want them have to be incredibly assertive about getting one done and following up to get the results. When my father died we had to hound the hospital to do one, waited two years for the report, and in the end we paid a pathologist in the US to interpret the findings for us.

  • Karl Hallowell

    I see several important questions here. First, are there other means for auditing medical care deaths? Second, how much do autopsies cost? For example, it probably wouldn’t cost that much just to look over the treatment history of the patient and observe whether certain types of mistakes (such as wrong drugs, treatments, or long delays) or suspicious activity (forged or missing documents) occurred. Given that probably has low cost, I wouldn’t be surprised if almost every medical care death has some sort of review.

    As to price of autopsies, they apparently range from say $500 for blood toxicity tests to perhaps $4000 for full body autopsies. So if 20% instead of 5% of patient deaths went to full body autopsy, that would increase cost of dying in a hospital by an average of $600 per death. That’s a bit stiff in absolute terms for a no-suspicion audit. But I gather hospital costs for that final part of life can be two to three orders of magnitude greater, which puts it in typical audit territory (I gather from my limited experience that business audits tend to be in that range of cost relative to the overall cash flow they are auditing).

  • Jake

    Four counterpoints to consider:

    1) More autopsies = more money for doctors because they are the ones who have to perform them
    2) Most hospitals are not owned or run by doctors – these hospital OWNERS are the ones who would want a reduction in autopsies to reduce medical errors paid for by their malpractice insurance
    3) Does medicare/medicaid and/or insurance automatically pay for autopsies? in fact, they probably automatically deny all requests for autopsies and force a fight
    4) At a more basic level, there are risks associated with participating in healthcare and the rise of people willing to undergo more risky, new procedures has to have something to do with this – and I would bet in a more perfect world doctors themselves would request way more autopsies so they can get better

  • Dave

    I have a lot of inside information in this area. The decline in autopsies started when hospital accreditation organizations quit requiring a certain percentage. Then autopsies gradually declined. I can’t pinpoint a clear reason.

    The hospitals did them gratis for inpatients. There was no money in them.Doing one is arduous and time consuming.They were usually initiated by the attending doctors,who genuinely wanted to know why their patient had died.

    Believe it or not doctors are usually stunned if the autopsy shows they made a mistake. They are a self confident bunch. Few autopsies show any major goof up. The lay public is totally misled thinking that there is a cover up mentality here. Shame on you Robin.

    The biggest problem you find that could get the doc in trouble is pulmonary embolism,which is always high on the list in sudden hospital death.

    Litigation could be part of the problem. When new treatments come out there can be problems. For example when the first came out with artificial heart valves the plastic ball valve could swell up and jam after ten or so years.It used to be the patient’s family was grateful for that ten years. Now if you watch TV there are solicitations by lawyers for any and all possible mishaps.

  • http://speculative-nonfiction.blogspot.com Michael Caton

    Full disclosure, I’m both a fan of Robin Hanson and a medical student, so I often wince when he gives special attention to my (future) profession – which is an ongoing theme here at OB.

    First, it should not be surprising that physicians are very interested in getting paid, and that unfortunately not all of them are equally interested with delivering the service they’re supposed to be providing in exchange, if people are letting them get away with it. Is this actually surprising? Put crudely, if a lab animal can get to a reward without doing the task you’ve assigned, guess what? That’s what it’ll do. So will I. So will you. While this is a problem that needs attention, it’s no better or worse than the situation that obtains in every other profession. And possibly the prestige the public gives to physicians is out of proportion to the value they create and to the characters of the people in the profession, which are (obviously) just as flawed as those of any other human.

    Second, I’m going to take a deep breath here and say that physicians sometiems come in for special criticism from other intellectual fields (not just from Hanson) so of course I often wonder why. If I can venture a guess, it’s that (many) physicians are paid well, and they reap more prestige from their intellectual position in terms of status if only because they interact more often with non-experts in the lay public who are easier to impress than other academics. But while people are telling them docs smart they are, their jobs are frankly more like the work of a mechanic rather than a scientist or even an engineer. So I can imagine that this disconnect would annoy other advanced-degree-folks who measure themselves in terms of the status and material compensation they’ve achieved through their intellects.

    Of course, there are also blowhard, bad-critical-thinking MDs out there who don’t help this perception because they get Ford-Chomsky syndrome and start thinking their qualifications in one area qualify them as experts in all human knowledge. In my experience, this is a small minority, although Oprah sometimes hires them, which exacerbates the problem.

    If irritation at misplaced rewards is what motivates this special scrutiny that MDs receive, AND if academics don’t like to think of their own behavior as subject to the same incentivization that every humans’ behavior is, then we should predict that pointing out this possibility would raise blood pressure. And indeed I’m often surprised at the personal attacks I’ve encountered when I raise these questions and do my best to signal that I’m asking only because I’m genuinely curious. Here’s hoping that my fellow OB readers are more circumspect than that.

    • Dave

      “Put crudely, if a lab animal can get to a reward without doing the task you’ve assigned, guess what? That’s what it’ll do. So will I.”

      So you are saying that professionalism, including yours is a fraud.You are not even through med school and that’s what you say?

    • Evil Mammoth

      “…their jobs are frankly more like the work of a mechanic rather than a scientist or even an engineer.”

      At first read, I’m mostly on board with your comments. I’m just wondering about the quote above.

      Would you extend this estimation to doctors who primarily do research, or are you mostly talking about clinicians? Seems to me this is a rather uncharitable view of your own profession in either case — not that you should attempt to be especially biased in your own favor. Perhaps being a doctor is analogous to being a mechanic, but the machine you’re working on is pretty damned complex.

      If there is a distinction between the intellectual output of the other professions to which you refer and that of a doctor, I don’t see that one is necessarily more or less valuable than the other (regardless of Hanson’s staunch condemnation of medicine’s usefulness at the margins). Maybe you’re correct about the source of prejudice from experts in other disciplines.

      I suppose I echo Dave’s concern at your admission that you would take shortcuts if provided the chance. However, I read that comment to say that none of us are, situationally, immune from that temptation.

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  • Nate

    It’s easy to see the selfishness of the doctors (who, as Michael points out, are only human after all).

    It’s a bit harder to point to the collective selfishness of the patient, specifically the grieving family members. Grieving family members don’t make good Bad Guys.

    But I have a strong suspicion that the increased accessibility to lawyers willing to help family members file lawsuits plays a large role in the decline in autopsies. If hospital accreditation continued to require high numbers of autopsies, the general service of hospitals would be driven into bankruptcy by lawsuits.

    Somehow, we continue to manage to take individuals with individual interests and create cooperative societies. It isn’t perfectly efficient, but it’s the only way to do it.

    • http://daedalus2u.blogspot.com/ daedalus2u

      I think it would be used more by insurance companies as a way to renege on paying for treatments that the autopsy suggested were not necessary. Or to pay doctors who misdiagnose patients less. Or pay hospitals with a pattern of misdiagnoses less.

      The problem with this approach is that it penalized doctors for taking difficult cases. If doctors have a choice in who they treat (and they do), then doctors who only treat easy cases will have a much better treatment metric than those who treat everyone, or those who treat the difficult cases that the easy case doctors refuse to treat.

      Eventually it would end up like all the other “professions”, where “experts” are “hired” to give specific advice that benefits those doing the hiring. Sort of like what the credit raters were doing before the financial crisis. Sort of like what the AGW deniers are doing now. No information is better than information deliberately skewed to fit an agenda.

    • Matthew

      Lawyers want to regulate every profession but their own.

      • Doug S.

        Not true! The practice of lawyering is itself highly regulated.

  • Mage

    Greed killed autopsies, least that I think it was. Unfortunately due to massive work regarding this matter, docs really find it too tasky to do this thing. Not only that, I think its a much better way for them to say we are the experts in this field, we know what we do and that is autopsies aren’t necessary. Period.

  • Matthew

    Robin

    Your superficial analysis is clear evidence that you are jealous of doctors.

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  • Doctor’s husband

    I think the idea that Medicine is a lucrative or greedy field is misplaced. This is just my personal anecdote so treat with the appropriate salt grains…

    My wife is about to finish her residency in pediatrics and then go on to a fellowship in endocrinology. By the time she is done with this she will have committed fully 15 years of her life to training to be a physician (4 years pre-med, 1 year master’s of public health, 4 years med school, 3 years residency, 3 years fellowship). In the process she has amassed several hundred thousand dollars in debt and (perhaps more importantly) lost about a decade of prime income earning potential. Even though she will get well-paid as a pediatric endocrinologist, she simply will not make up the lost earnings she would have accrued if she had just started working our of college (Molecular & Cell biology background from top-10 university) or after her master’s degree (from an Ivy league school). In addition, she works hellacious hours – currently on a set of 5 straight 8pm-10am night shifts which will be repeated again next week.

    All this is to say that if money is prime to a person’s motivations, then becoming a doctor is not a rational approach. You really have to want to be a doctor to become a doctor.

  • livex

    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. This can explain doc “fear of litigation”, dislike for autopsies that might disagree with tech diagnoses, and lobbying to cut accreditation rules requiring autopsy funding.
    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?

    Could there be any clearer example of someone putting forth a speculative hypothesis with no evidence and then treating it as established fact?

  • eric

    “Could there be any clearer evidence that docs care more about getting paid than about healing patients”

    Yes, in fact, there could be. Especially given the fact that few autopsies isn’t evidence of this malicious point to begin with. As a physician I’ll tell you exactly why there are few autopsies– public attitudes towards autopsy have changed. It is not at the doctor’s discretion to perform an autopsy. I need the consent of the patient’s family to perform one and cannot deny them an autopsy if they request it. There is also no evidence that increased rates of autopsy lead to increased litigation. I offer the option of an autopsy to the family of every patient that passes away under my care and 5% is a good ballpark number for how many people want one– my number is maybe slightly higher.

    Moreover, when patients are interested in an autopsy doctors by and large are very receptive. We almost always learn something we did not prior to the patient’s death and that can help us take better care of our future patients. In fact, the controversy around autopsies in the 1960s was that we were being too coercive in talking people INTO performing autopsies. The novel House of God satirizes this nicely with their “black crow” award for the intern who gets the most post-mortems. I guess you’re damned if you do damned if you don’t.

    The few times in my career I have had a big disagreement with a family over an autopsy has been the opposite problem Ms. Hansen cites– when a patient dies under certain circumstances we are required to contact the medical examiner who may request an autopsy. See ‘deaths reportable to coroner” http://www.vchca.org/medical-examiner.aspx. I’ve had two cases with elderly patients admitted with fractured hips who pass away (hip fracture mortality is 25% in the elderly) and the coroner feels the fall that broke their hip was an “accident” so it requires a brief investigation. While such investigations often only involve review of medical records and an external exam of the patient they legally retain the right to perform a full autopsy and I’ve had families quite upset that that decision was made for them. In both cases their loved one was quite ill before the hip fracture, they didn’t feel the autopsy was necessary, and they strongly preferred not to have one. At that point its out of our hands though– the ME has a legal right to investigate.

    Anyway, I don’t find the argument that physicians are suppressing a clamoring public demand for post-mortem examinations very credible based on my experience.

  • RickG

    “autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time”

    The caveat here is that autopsies are largely done in the 5% of cases when the cause of death is uncertain in the first place, so by definition the clinicians aren’t particularly likely to have come up with the right diagonosis. Without this context you make it seem like the clinician is wrong about cause of death in 40% of all deaths, which is absurd.

    As long as malpractice decisions and awards are determined by a panel of 12 people, from whom people with scientific or medical knowledge have been excluded by the plaintiff’s lawyers, and who have a strong bias (as we all do) towards assigning agency to all bad things that happen, which means a bias towards blaming doctors for circumstance beyond their control, it is unreasonable to expect doctors and hospitals to go out of their way to uncover all the evidence in the event of a patient’s death.

    Many hospital departments’ doctors do have frequent group meetings among themselves (called Morbidity and Mortality report) where they discuss causes of downturn or death in patients, and are presumably learning things that might help reduce the future likelihood of these events (not necessarily in the professional as a whole, but longitudinally in each doctor’s career). For obvious reasons, these meetings are private, and until malpractice is reformed, there is a strong disincentive to this information being shared with anybody.

  • Andrea Bateman

    This is the most amazingly biased post I have read in a long time, funny it is on a blog called “Overcoming Bias”! Five minutes of researching on Google could have given the author much more insight than jumping to the conclusion that doctors are greedy and don’t want to be wrong. Firstly, there is a worldwide shortage of pathologists, the doctors who perform autopsies. Why, you wonder? Well, no one pays for autopsies. Medicare will pay a lump sum to the hospital based on diagnosis code, so after everything and everyone else is paid there “may” be money left over for an autopsy. Insurance companies don’t pay, they say benefits to the recipient end at death. Families often can’t pay on top of all the other medical bills. So most of the autopsies done are ones where the cause of death is in question, and those will often discover a different condition than what was listed on the death certificate.
    Robin, if you are going to do a post, check your biases at the door and do your research so you don’t look like an idiot next time.

  • eric

    For the record our hospital does not require families or their insurance to pay for an autopsy if they choose to have one. Most families simply don’t want one. To the extent that we discuss autopsies (which is very, very little) the discussion usually centers around how to address people’s concerns about having one done– can we have an open casket, we don’t want them ‘mutilated,’ cost, etc.

    And, yes, I’m just now seeing that the title of this blog is “overcoming bias.” HA! I wonder what kind of biases the author brings to the table that allows her to make the leap from “fewer autopsies are being performed than were in the ’60s” to “doctors are callous, greedy, and don’t want autopsy results undermining them.”

    There is literally no stepping stone between those two statements. The author just states that one, of course, leads one to conclude the second. Please. The author needs to print a correction, an apology, or provide some MUCH better support for her inflammatory statements.

  • DS

    Autopsies of patients who die in the hospital are only performed if the next of kin consents for autopsy unless the death is somehow deemed suspicious (e.g. possible homicide). In cases where the death is unexpected or otherwise deemed suspicious, it is an automatic medical examiner’s case and autopsy is performed even if the family does not consent.

    Are some physicians greedy? Of course. Do some physicians have egos the size of a house? Absolutely. But when you consider the amount of training time before earning attending-level income, the tremendous financial debt we take on during our training time, and the fairly solid ceiling on physician income by specialty (as opposed to, say, a hedge fund manager), becoming a doctor turns out to be a pretty inefficient way to make some serious cash. The fellow physicians I know, by and large, fully embrace our role as detectives – as such, we are very interested in knowing what determines our patients’ course of illness and/or death.

  • GLS

    I realize that the author (RH) will sometimes write an intentionally inflammatory post and this might be the case here. I also know his opinion of certain unchallenged assumptions (schooling and healthcare produce what you think they do, except that they don’t) and that those revered in our society are not always worthy because of intense conflicts of interest. One very pervasive idea in society seems to be a conspiracy theory regarding the covering up of medical mistakes, which the author’s post subscribes to. Having practiced medicine in three different continents now, I have never seen any evidence of this (maybe it is really, really well covered up?). In fact, quite the opposite seems to apply, with strong emphasis on quality control (random morbidity and mortality reviews) and determination to uncover the source of medical errors, which are frequently systemic. Many hospitals have whole departments devoted to this, partly to comply with regulatory agentcies who often make surprise visits to conduct intense and detailed audits. But all this does little to persuade the skeptics who might argue that these controls just simply make it harder for the doctors to do what they would prefer to do, which is cover up their mistakes. My experience of my colleagues has been that their desire to uncover the truth far outweighs any concern for the consequences of learning the truth.
    In spite of RH’s pet peeves, I suspect he wrote the post to stimulate just the sort of discussion that has ensued, but even this has not produced any more evidence (other than anecdotal) to truly and rationally evaluate the potential causes of the declining post-mortem rate, and even then, RH knows all too well that correlation is not a cause.

    • billswift

      It’s not a conspiracy – most doctors just have their heads so far up their butts that they don’t see their own incompetence. Read Atul Gawande’s The Checklist Manifesto and have your eyes opened.

  • eric

    Thanks for clarifying GLS, I’m not that familiar with this blog. I guess the author is interested in overcoming everyone’s bias but his own.

    • GLS

      eric, sadly you are referring to a few brave souls who volunteered for a program that grew out of the self-examination movement (breast, testicle), namely, the Continuous Colonoscopy Initiative, which unfortunately backfired. Discussion now centers on how best to perform cranio-colonic extraction, Class 1 evidence is lacking and industry funded studies are notoriously biased anyway. Others are concerned that even if their heads could be safely extracted from their butts, said heads would be by now so full of crap that they would be useless for anything other than practicing medicine at VA (Veteran’s Affairs) facilities where, mericfully, they cannot be sued for malpractice. Experts are being brought in from other successful government cover-up programs (Tuskagee, Kennedy assasination, Potemkin, Watergate, Iran-Contra, Edwards baby, and Obama birth certificate) for damage control and this post will self-destruct in 3 seco______

  • http://www.hopeanon.typepad.com Hopefully Anonymous

    “… and lobbying to cut accreditation rules requiring autopsy funding.”

    What are the cites for this, and how do skeptics respond to this particular point?

    All I got from the linked Washpost article is

    “Until 1970, hospitals had to autopsy at least 20 percent of their patients in order to remain accredited. Once that requirement was dropped, autopsy rates began to fall, due to lack of direct funding, fear of litigation and increasing reliance on technology as a diagnostic tool, among other reasons.”

    • http://www.uweb.ucsb.edu/~criedel/ Jess Riedel

      I figure it is hospitals, not doctors, who lobbied to have these accreditation rules relaxed. Which would be completely unsurprising, and not evidence of any wrong-doing.

      I’d very much like a cite.

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  • mulp

    How about looking at actual investigative reporting on the topic:

    PBS Frontline: Post Mortem – reporting by Frontline, ProPublica, and NPR. FRONTLINE producer/correspondent Lowell Bergman, ProPublica reporter A.C. Thompson, NPR Investigative Unit reporter Sandra Bartlett, UC Berkeley’s Investigative Reporting Project reporter Ryan Gabrielson,….

    If good autopsies aren’t performed for extremely suspicious deaths, where crimes are likely, for lack of competent medical examiners, why would you expect them broadly done for reasons of science?

    “THEY ARE EXPENSIVE
    Autopsies are not covered under Medicare, Medicaid or most insurance plans, though some hospitals — teaching hospitals in particular — do not charge for autopsies of individuals who passed away in the facility. A private autopsy by an outside expert can cost between $3,000 and $5,000. In some cases, there may be an additional charge for the transportation of the body to and from the autopsy facility.”

    How about an economist making the case for paying for autopsies by: – the dead person,
    – the attending physician,
    – the hospital,
    – the heirs,
    – the government,
    – the ambulance chasing lawyer

    The lawyer has a clear profit motive justification, Who benefits otherwise?

    And from the report, I’d guess the doctor could perform the autopsy on his dead patient as long as the government official signs off on the death before it is done. Seldom is skill, much less any certification, required to cut open a body for something called an autopsy.

  • Michael Loewinger

    I practice at a teaching hospital in New Jersey. The author has a nice theory and I am always in favor of being as cynical as possible, but my experience just does not bear out what he says. Since we are a teaching hospital the administration is always trying to get more autopsies and there’s a meeting every year about how we can get more. Everyone is required to ask for an autopsy for every patient. The main reason doctors don’t ask is because it’s very uncomfortable. Imagine, you took care of a patient for a week, he just died and the family is grieving and now you have to ask “Can we autopsy your dad?” No one likes it. Then, 95% of the time they say no. You could spend another 15 minutes talking to them about the good of medical science to try to persuade them, but no one wants to do that unless it’s a particularly interesting or mysterious case. Autopsies are paid for by the hospital and none of the people who actually make the decision to do an autopsy, so I don’t think that’s a reason for the decline, and with the current low number of autopsies it’s just not that much of a burden. Lawsuits could be an issue, but by the time the patent is dead, the doctor-patient relationship is pretty much set and most of the useful information is already in the chart. Doctors talk about lawsuit worries a lot and I’ve never heard anyone express any concern over possible autopsy findings. Every doctor I’ve spoken to has would like more autopsies if they could get them. They just don’t want to spend15 minutes convincing family members to get one.
    In conclusion, it’s a nice cynical theory which I like, but I don’t think it’s the actual reason. I think the actual reasons are emotional and cultural. 1) Doctors don’t like asking newly grieving families for autopsies. It’s uncomfortable. 2) Our culture has changed and people don’t consider autopsies routine anymore and don’t want them. 3) Dropping the formal 20% requirement I’m sure made all the difference. Before you had to do whatever it took to get families to agree to autopsies or lose accreditiation. Now you can just ask “Can we do an autopsy?”. “No.” “Ok.” done.

    • http://www.hopeanon.typepad.com Hopefully Anonymous

      Interesting info.
      From this comment, it seems to me that autopsies are like organ donations, we’d probably benefit if the default was autopsy + organ donation, advance permission not required.

    • Danny

      I’m curious why you wait until the patient has died? If I’m on my deathbed, ask me, not my family after I’ve passed. It should be my decision first.

  • Mark B

    “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?”

    As long as we’re making up theories with no attempt at validation, how about this one: “Autopsy rates have fallen dramatically during a time period in which patients and patient’s families have asserted a stronger role in medical decisions. Patient’s families frequently claim that they can’t bear to see their loved ones carved up in an autopsy, after they already suffered so much. Could there be any clearer evidence that patient’s families care more about hiding their guilt, covering up their direct role in murdering their own family, than in healing patients? And yet the public cannot bring itself to imagine families that are murderers.” ?

    I think my theory is about as good as yours.