A Look Inside: Autopsies, Medical Arrogance and Misdiagnosis
Writing in a 2001 issue of the New Yorker, Atul Gawande recounts the unease doctors nowadays feel when asking families for permission to perform autopsies. The autopsy, once a routine part of death in Western medicine in the 20th century, is now a rarity. At the time of Gawande’s writing in 2001, autopsies were done on less than ten percent (8.1%) of all deaths, compared to on almost half of hospital deaths at mid-century. This statistic hasn’t changed much since Gawande’s article was published, according to the last available report in 2007 by the National Center for Health Statistics.
What intrigues Atul Gawande — and the question he attempts to answer in this piece — is why the rate at which autopsies are performed post-mortem declined so rapidly. Not from families refusing after doctors ask — families still give permission to perform an autopsy in 80% of cases. Rather, doctors are increasingly hesitant to ask for autopsies, particularly when families are despondent and there seems to be a discernible cause of death. “Doctors, once so eager to perform autopsies that they stole bodies, have simply stopped asking,” Gawande describes. Confident in their diagnoses for cause of death, physicians feel no need to dissect a solved puzzle.
Atul Gawande is a surgeon at Brigham and Women’s Hospital in Boston, professor at Harvard Medical School and a best-selling author. His knowledge on this subject — life, death and open bodies — is profound and greatly informs his piece. Gawande allows his personal experience with death and autopsies to guide his discussion and humanize the practice of dissection. For example, Gawande goes into graphic detail about the dissection — from the first Y-shaped incision — of a thirty-eight-year-old woman who had been in his care. Nevertheless, he describes the natural human aversion to opening the body, especially in death: even as a surgeon, Gawande remembers feeling squeamish watching the evisceration of a patient he cared for only a few days prior. Additionally, he describes his own emotional inability to ask the spouse of a recently deceased patient — Mr. Sykes — for an autopsy on her husband.
Autopsy, from the Greek autopsia, literally means “to see for oneself,” and for most of its history the autopsy functioned as a way for physicians to learn more about visceral processes hidden within the body. In his article, Gawande briefly describes the history of autopsies and dissection in Western medicine, and in doing so elucidates — as Katharine Park does in her history of anatomy in Secrets of Women — why the context of how and for what reason a body was opened is of utmost importance.
While the autopsy has been around for more than two thousand years, for most of this time human dissection was rarely performed. Autopsies were performed on important figures — Julius Caesar in 44 B.C. and Pope Alexander V in 1410 A.D. to name a few — in order to determine cause of death and/or ensure no foul play. Even as the medical profession formalized and religious reproach eased in the medieval and early modern period, autopsies remained infrequent occurrences; in the 19th century with limited access to cadavers, doctors performed clandestine autopsies on their patients or would rob graves in order to obtain bodies for dissection.
Only in the early 20th century did the practice of autopsy become commonplace. Popularized by physicians Rudolf Virchow, Karl Rokitansky, and William Osler, autopsies functioned as a discovery tool, just as they did centuries before, yet now doctors were criticized if they did not perform an autopsy. After insuring dignified and respectful dissection practices, doctors were able to sway public opinion toward the need for autopsies by claiming that they helped to prevent future medical errors, while also giving family members answers at a time when most deaths were a mystery. Therefore, in a context when death was concealed within the body, doctors turned inward to closely examine the internal pathology of a deceased patient. Without the medical knowledge or technology available today to make an informed diagnosis about a patient’s condition, early 20th century physicians relied on the autopsy to reveal the truth.
Twenty-first century medicine is marked by substantial advancements in diagnostic technologies — the CT scan, X-ray, nuclear imaging, ultrasound, and molecular testing — that function as windows into the body. Due to these modern technological advancements in medical testing, autopsies seem redundant or unnecessary to many physicians — they are unlikely to expose anything new to an all-knowing physician. At a time when medical progress seemingly allows doctors to both understand and predict the intricacies of the human body, clinicians do not feel the need to open bodies to confirm what they think they already know.
Gawande challenges this medical arrogance with both staggering statistics and a personal account. According to studies completed in 1999, 40% of autopsies reveal a misdiagnosis at the time of death. Additionally, when comparing misdiagnosis rates across decades after the incorporation of diagnostic tools such as the CT scanner, Gawande describes that “the rates at which misdiagnosis is detected have not improved in autopsy studies since at least 1938.” So are physicians just terrible at their jobs? Is technology failing us? This statistic is baffling, but it is important to point out that Gawande, in reporting this statistic, does not address what percentage of autopsies are performed on specifically perplexing cases. Even still, it’s hard to accept that the medical profession has failed to improve their diagnoses over time. In my own research into these numbers, I could not find a study that verifies Gawande’s 40% statistic. According to a recent meta-analysis of autopsies performed in intensive care units, 28% of autopsies report at least one misdiagnosis at the time of death. While less than the misdiagnosis rate Gawande cites, this number is still concerning.
In terms of his personal practice, Gawande recounts a time when an autopsy revealed that he misdiagnosed a patient (“Mr. Jolly”) who “did not seem to have an undiseased artery in him.” Sure that Mr. Jolly’s sudden death was the result of a pulmonary embolism — after running tests to eliminate all other possible options — Gawande discovers at autopsy that the man ruptured an aortic aneurysm and instantly bled to death; the X-ray failed to reveal any indication of such and nothing could have been done. Truth, according to Gawande, was only found in the experience, sensation, and verification of the real body.
In an argument for the necessity of routine autopsies in medical practice, Gawande highlights the individuality of people, of bodies, and of life-stories. Why do doctors presume that every patient with a certain condition is like all others? Doctors are trained to think that their patients’ conditions are predictable, fitting into the discrete, diagnostic criteria that the practice carefully constructs. Advancements in medical technologies have only deepened a practicing physician’s confidence in their diagnosis — and arrogance. Gawande argues for autopsies because doctors are not all-knowing: their interpretations can be wrong, tests misleading. As in his example with Mr. Jolly, autopsies reveal the naked truth.
Just like the physicians of 14th century Italy who pioneered public dissection in the west, Gawande also stresses the importance of the autopsy for furthering scientific knowledge and serving the public good. In this way, Gawande’s support for autopsies mirrors that of medieval physicians who began to formally incorporate dissections into medical teaching. While dissections and autopsies of today are by no means as public as those in 14th century Italy — when a criminal’s dissection was on view for the layperson to see — there is a sense from Gawande’s article that he believes autopsies serve the same purpose: to know more about an individual for the common good of the collective.
