Pathology: Lessons from the Dead

“H. L. Mencken defined a judge as a law student who grades his own papers,” writes Manhattan Internist John Prutting in the New York State Journal of Medicine. “A similar view might be taken of the physician who fails to submit his diagnostic skills to that impartial grader, the autopsy.” With that, Dr. Prutting put in a plea for more autopsies, which would enable more doctors to compare more diagnoses with actual causes of death.

Only about 30% of U.S. deaths are followed by autopsies, and when postmortem findings are compared with ante-mortem diagnoses, glaring discrepancies often occur. Less than 50% of all cases of pulmonary embolism (in which a massive blood clot travels to the lungs) is correctly diagnosed before death. In 200 cases of bleeding from the gastrointestinal tract, the diagnosis was wrong 33% of the time, and 37 cases of bleeding peptic ulcer were missed. Among 85 cases of liver abscess, 53 were unsuspected until the autopsy.

Dr. Prutting concedes that diagnosis is improving. But he insists that even ultramodern technical aids do not make it infallible, so the findings should always be checked. To rouse physicians, Dr. Prutting urges hospital pathologists to educate their colleagues at weekly “organ recitals” for comparison of diagnoses and autopsy findings. This still might not increase the number of autopsies substantially, for in most states, if death occurs in a hospital or is not “suspicious,” an autopsy is illegal without consent of the next of kin. Dr. Prutting suggests that “archaic state laws” should be revised so that consent is not required, and the dead can aid the living.