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:
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.
Not true! The practice of lawyering is itself highly regulated.
"...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 &#8212 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.
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.
"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.
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.
... 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.
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 EXPENSIVEAutopsies 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.
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.
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.
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______
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.
"... 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."
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.
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.
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.