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Medical uncertainty and the autopsy: occult benefits for students
Symposium Medical Uncertainty and the Autopsy: Occult Benefits for Students ROBERT E. ANDERSON, MD, RENiE C. FOX, PHD,AND ROLLA B, HILL, MD The autopsy has been of great importance in educating students regarding medical uncertainty. The marked decline in the use of the autopsy in medical education and continuing education has contributed significantly to the current discomfort among phy sicians regarding medical uncertainty and medical errors, which, in turn, has furthered the decline of the autopsy. Inordinate guilt, denial, and other defensive behaviors that many physicians marshall in response to uncertainty and error prevent these individuals from learning from their mistakes. The autopsy experience during medical school, properly utilized, helps students to confront fallibility and sets the stage for later successful management of uncertainty and error. HUM PATHOL 21:129-135. 0 1990 by W.B. Saunders Company.
The role of the autopsy in helping medical students learn to accept and cope with the uncertainty inherent in the practice of medicine was extensively explored by one of the authors (R.C.F.) as a part of her studies concerning the sociology of medical education, conducted by the Bureau of Applied Social Research of Columbia University, in the mid-1950s.’ At that time, autopsy practice was in its heyday in the United States: over 50% of patients dying in hospitals in the United States underwent autopsy; physicians and students were in attendance at virtually every autopsy; autopsy-derived information was used to educate groups of physicians by clinical-pathologic conferences (CPCs), published reports, etc; and the catalog of diseases, as well as the very definition of disease, was learned by medical students from autopsy studies during medical school. Prior to the study referred to above, however, few educators had recognized the value of the autopsy in introducing students to the phenomenon of medical uncertainty.2 The other two authors of this report came across these studies while attempting to understand the surprisingly high rate of discrepancies regularly found between diagnoses made premortem by clinicians and those made postmortem by pathologists at autopsy.gs4
The mixing of the concepts of the autopsy as training for uncertainty and as the proof of uncertainty inherent in medical diagnostics led to an interesting exchange of ideas and opinions among the three of us. The distillate of these discussions forms the basis of this presentation. We start by reproducing portions of the early essay,’ since it is still apt and not well-known to physicians.* “This essay examines an event experienced by all second-year students at a medical college: the first autopsy they attend as part of their course in general pathology. It begins with the premise, shared by many medical educators, that the autopsy room is one of the important ‘halls of learning’5 in which medical students are trained to be physicians, and it goes on to suggest that the experience of the autopsy serves to transmit to students, in ways planned and unplanned, some of the attitudes and values, as well as knowledge and skills, required for the effective performance of the role of physician.” The author included an exploration of the autopsy experience as an aid to developing scientific detachment in the face of events with major emotional impact. Students often “make a self-conscious effort to enhance their objectivity by deliberately focusing on (the) scientific aspects.” The behavior of the prosector, “impersonal, matter-of-course,” provides a role model. TRAINING FOR UNCERTAINTY “The zautopsy plays a major role in training students for uncertainty, the process by which students learn about some of the uncertainties of medicine and develop ways of coping with them.“* KINDS OF UNCERTAINTY IN THE AUTOPSY
From the Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM: Department of Sociology, University of Pennsylvania, School of Arts and Sciences, Philadelphia, PA; and the Department of Pathology, State University of New York, Health Science Center, Syracuse, NY. Key won&: uncertainty, medical error, autopsy, medical education. Address reprint requests to Robert E. Anderson, MD, Department of Pathology. University of New Mexico School of Medicine, Albuquerque, NM 87 13 1. 0 1990 by W.B. Saunders Company. 0046-8 177/90/2102-0002$5.00/O
“Every doctor encounters three basic types of uncertainty: uncertainty that derives from limits on the state of medical knowledge; uncertainty that grows out of his imperfect mastery of all that is known; and
*Fox RC: The autopsy: Its place in the attitude-learning of second-year students, in Essays in Medical Sociology, Journeys Into the Field. Copyright 0 1979 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons.
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uncertaintv over how to distinguish between his own ignorance or ineptitude and the restricted powers of medicine itself, Second-year students are exposed simultaneously to all three kinds of uncertainty when they take part in autopsies. Since an autopsy is an organized attempt of pathologists and clinicians to resolve some of the uncertainties of a case by conducting a postmortem examination, students are also being introduced to one of the institutionalized ways in which physicians in a teaching and research center deal with uncertainty. Finally, the autopsy tests and advances the ability of students to come to terms with uncertaintv. “Panicipation in an autopsy makes students nlore aware in various ways of the uncertainties that result from limited medical knowledge. To begin with, being put on call for an autopsy reminds them that even when death is expected, the exact time of death is sleldom predictable. “Students become impressed by the limitations of current medical knowledge when they see that the autopsy-.the final and presumably exhaustive examination of the patient-often fails to tell what was the cause of the patient’s death. Even when the autopsy provides an answer, it is often less ‘dramatic’ and ‘specific’ than students expected it to be:
upon students during their participation in an autopsy. For example, the autopsy gives students an opportunity to observe that ‘the doctors aren’t always sure what caused the patient’s death’ or whether they could have done something to forestall it. As one student puts it, ‘they come to the autopsv to find [these things] out:’ “Students may be present at an autopsy in which it becomes apparent that the phvsician was mistaken in his medical judgments: My roommate had his autopsy l.nst week. And there were lots of things supposed to be wrong with this case. Well, as you know, the \.arious doctors who were involved in the case wander down white the autopsy is going on, and come in to see what was wrong with the patient. In my roommate’s case, they just weren’t finding anything in the doctor’s diagnoses “From experiences such as these, students may learn that because ‘medical knowledge is so vast’ and ‘there’s always so much to be taken into account, even the finest phvsicians’ do not command all the available informaiion relevant to each case they handle. Their medical knowledge, of course, is greater and more seasoned than that of medical students. But students have an opportunity to see in the autopsy that, nevertheless, mature physicians--like the students themselves -are confronted with uncertainties of diagnosis, therapy, and prognosis that grow out of their imperfect mastery of all there is to know in medicine. What is more, students can observe that lack of knowledge and its attendant uncertainty may have led ‘the best of doctors’ to misjudge a case. or to have ‘made mistakes’ that sometimes affected the welfare of the patient. “The third type of uncertainty the autopsy presents students derives from the first two: uncertainty over how to tell where the personal limitations of physicians leave off and the limitations of medical science begin. This is the kind of uncertaintv that an autopsy ought ideally to resolve. If the cl&icians could not make a diagnosis in a specific case. or failed to make a correct one, should they have been able to? Did they make the right therapeutic decisions? In short, given the current state of medical knowledge, could the death of the patient have been prevented? Unless unusual circumstances surround a case, such as the possibility that the patient’s death was due 1.0 ‘unnatural’ causes, or that some form of malpractice was involved, the pathologist who conducts the autopsy does not explicitly address himself to these questions. Nevertheless, they are always implicit in his postmortem examination. “The pathologist is often unable to answer some of the questions that were left unsolved by clinicians. When this is the case, it is generally because of the limitations of current medical knowledge rather than the ignorance or ineptitude of the clincians responsible for the case. But, . . . at some autopsies that students attend the pathologist is able to clear up some of the diagnostic and therapeutic uncertainties that
While our case was unusual, it was a bit of a letdown to me. f’or there was nothing dramatic to be pointed IO as the cause of death. The clinician reported that the patient had lost 1000~~. of blood from internal bleeding in the (2.1. tract. Well. we saw no gaping hole there. There was no one place you could pinpoint and say: “This is where the hemorrhage took place.” of a condition relating . . Kather, it was a culmination to various factors. I suppose most causes of death are this way. But still it was somewhat disquieting to me. “The extent of uncertainty at the end of an autopsy is often greater than students had anticipated. As a result, stlldents sometimes have difficulty in determining when the autopsy is over: I didn’t know the autopsy was over until I was told that it was. After going over each of the organs, Dr. L. continued to cut and to take pictures. Finally. at a certain point he had to tell us, “I guess that just about does it. YOU can go now.” But there’s really no finite point. You can’t say it ends here. “No matter how definitive an understanding of the ‘causes of the patient’s death’ that emerges from the autopsy, it remains obvious that physicians did not know how to prevent his death. This is conveyed to students primarily through the presence of various doctors connected with the case in the autopsy room and by the doctors’ discussions with the pathologist. In this way, stuclents become increasingly aware of another limitation in the field of medicine: its lack of control over death and the uncertainty with which physicians are confronted as a result of this limitation. “Not only the limits of the field, but the relationship between the personal limitations of physicians and the uncertainties they face become impressed 129
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clinicians left unsettled; in others, the findings of the pathologist contradict those previously arrived at by clinicians. When the latter happens, students may at first regard it as proof of the clinicians’ inadequacy in handling the case. But in many instances, the pathologist helps them see that ‘it is not as cut and dried as all that’: In the first autopsy I did with students this year, [a pathologist told us], the man was diagnosed as having a carcinoma of the stomach. During the course of the work-up on the patient, he suddenly died. It turned out that the pain in the patient’s stomach was not in the stomach, but in the liver. And what the patient died of was a tumor of the lung that was completely unsuspected. The students’ first reaction to this was, “what a ‘boo-boo’ on the part of the clinician!” What I did was say, “Here’s the chest x-ray done on the patient. Now you show me the cancer.” . Which they couldn’t. It wasn’t that visible. . . [I also tell students that] we try to write the autopsy up in such a way that doesn’t say, “Nyah, nyah, it was your fault.” Because it’s usually not as cut and dried as all that. “Students who assist a prosector with this point of view learn directly from him that it is often hard to distinguish between the ‘fault’ of the doctor and the ‘fault’ of the field of medicine.
“In sum, students learn from their first autopsies that, although death is inevitable, it presents physicians with several kinds of uncertainty that even a postmortem examination cannot always dispel. As we have seen, students react to these uncertainties with and chagrin. The realization surprise, discomfort, that death is something the doctor can neither ‘pinpoint’ nor easily prevent becomes especially ‘disquieting’ and ‘disappointing’ to them. On the whole, however, students seem able to cope successfully with the uncertainties presented by the autopsy.” BASIS OF COPING WITH UNCERTAINTY “By the time they are put on call for their first autopsy, second-year students have already had much * For one thing, even when training for uncertainty. they were freshmen, students were ‘given the major responsibility for learning’. In the non-spoonfeeding milieu of the first year at some medical schools . . information is not presented to them ‘in neat packets’; precise boundaries are not set on the amount of work expected of them; and they may not receive grades. Students have to find out for themselves how much they are expected to know, what they should learn, how they should go about it, and how well they are doing. Insofar as it teaches students to take responsibility in a relatively undefined situation, the non-spoon-feeding approach of their first year can be thought of as providing them with a foretaste of the ambiguities a physician encounters when he assumes responsibility for a patient. “First-year anatomy gave students their beginning awareness of the specific kind of uncertainty
that results from personal limitation. The venerable science of anatomy represents such a huge body of facts that, no matter how much time and energy they devoted to it, students found that they were unable to master all this knowledge. This experience helped students to see more clearly that they would always be faced with uncertainties derived from their inability to ‘know all there is to know.’ “Their course in pharmacology confronted students with the kind of uncertainty that stemmed from limitations of current medical knowledge. Pharmacology is a relatively tentative science . . . of experimentation. The study of pharmacology helped students to realize that not all the gaps in their knowledge indicated personal deficiencies. “Chiefly through their training in observation, students were also introduced to another kind of uncertainty before they assisted in their first autopsy. On the many occasions when they had trouble making some of the observations that their courses required of them (for example, visualizing anatomical entities or seeing what they were ‘supposed’ to be on a histological slide), they did not find it easy to decide how much of their difficulty was ‘personal’ and how much of it ‘had to do with factors outside [themselves].’ Their uncertainty was that of how to distinguish between their own limitations and those of medical knowledge itself. “Although the autopsy may be unique in exposing them simultaneously to all these types of uncertainty, students have had some prior experience with each type. “The ‘spirit’ in which they see pathologists and clinicians approach the autopsy also helps students to cope with these uncertainties. Students note that, in general, pathologists and clinicians at an autopsy freely acknowledge their uncertainties about the diagnosis and treatment of the case they are considering. (In fact, the autopsy is premised on their mutual willingness to do so, in order to learn from those uncertainties and thereby possibly to resolve some of them.) Because it gives students a chance to see mature scientists and physicians handle uncertainty in an open, affirmative way, the autopsy helps students to come to terms with their own uncertainties. It encourages them to accept their own uncertainty-to define some of it as ‘inevitable’ and ‘thoroughly legitimate’and to begin to cope with it by freely expressing that they are unsure. “Finally, the strains to which the uncertainties of the autopsy subject students are offset to some extent by these uncertainties deepening their scientific interest in the case
being
examined:
. . . Before the autopsy even began, you could tell from the clinical record that they hadn’t been too sure of what was wrong with the patient. In a way, I was hoping it wouldn’t be a clear-cut case. . Because it wasn’t clear-cut, it gave me a real desire to see the autopsy and try to find out what had really been the matter. I guess that’s one of the reasons why the emotional aspects of it were obscured. . There was the 130
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excitement of expecting one thing and finding another, and also many small things that hadn’t been anticipated.
concerned with disease and to anticipate the attendant alterations in homeostatic mechanisms. These changes have not been limited to pathology, and have led to the deemphasis of many of the more intimate, albeit time-consuming, medical student experiences -such as learning effective interviewing techniques and honing skills in physical diagnosis--in addition to the autopsy: These changes in the curriculum, resulting in conslderable diminution in the opportunities for students to undergo experiences in medical uncertainty. have been partly the result of changes in attitudes, and have in turn reinforced those additudinal changes. As a consequence, however, we run the risk of generating physicians who tail to understand that the science of medicine is highly inexact and that traditional approaches, including learning from one’s mistakes via the autopsy, have ongoing value.
“In sum, the autopsy presents students with various kinds of uncertainty and helps them to cope with each kind. It makes students more nearly aware that some of their uncertainty does not differ from that facing doctors and that candor about such uncertainties is expected and approved. This realization, along with their prctvious experiences with uncertainty and rheir intellectual attraction to cases that have some elements of unexpectedness, seem to enable students to come to terms with the uncertainties of the autopsy.” The essay concludes with short discussions of the role of the autopsy in providing training in the management of time, medical morality, and professional self-image and declares that “the first autopsy is a ‘rite de passage,’ a ‘landmark’ or ‘milestone’ event along the road to becoming a doctor that attitudinatty and symbolically incorporates students more fultv into the profession.” We will now expand the discussion of medical uncertainty and the autopsy, particularly with respect to the impact on medical students, in light of the evolutionary changes that have transpired in the 30 )ears since the above essay was written. We will be particularly concerned with the plummeting autopsy rate, some of‘ the reasons for that decline based on perceptioms of medical uncertainty, and some of the results of the decline, especially on medical education.
AUTOPSY AS CONTtNUtNG EDUCATtON For the physicians who arc the students’ teachers and role models, use of the autopsy to rleveal errors in medical care was a matter of acknowledged importance for many decades. Prior to the second half of the 20th century, the autopsy had contributed much of the scientific basis for the practice of medicine. The best clinicians, although understandably proud of their clinical acumen, freely acknowledged the limits of their knowledge, and looked to the findings from autopsies to help liberate them from their ignorance. A story about William Osler illustrates this attitude. Osler once had a patient “whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. I)r Osler seemed delighted, sent especially for all those in his ward classes: showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it.“; The physicians brought their students to the autopsy room, where the latter not only learned about disease, but listened to their mentors discussing errors in medical care with the pathologist. as described by Fox.’ Physicians expected themselves, their peers, and their students to learn, and to profit, from their mistakes. That mistakes were inevitable was universally accepted. The autopsy represented a unique opportunity to expand simultaneously the scientific basis of medicine, the knowledge of the students of the discipline, and the experience of the individual physician, as well as the chance to learn from errors. Today, the emphasis seems to have shifted. Many physicians seem more intent on hitting from, or otherwise avoiding, their mistakes than in learning from them. ‘l’he understanding that errors are an inevitable consequence of patient-physician interactions and that one can learn from one’s errors has given way to the unfortunate misconception that errors constitute such a failure as to be virtuallv inadmissible. And no
AUTOPSY IN THE MEDtCAL CURRtCULUM When the above article was written, the autopsy was a central part of the medical curriculum in most medical schools in the United States. By contrast, a recent survey of US academic departments of pathology revealed that less than half (42%‘) require that their students participate in an autopsy and, even in departments in which there were such requirements, the number of cases rarely exceeded one.” 1t is difficult to conceive how one case in isolation could accomplish the many values noted in the paper quoted above. One need only to remember that first autopsy experience, and the plethora of new feelings and stimuli, to understand that while much was learned, most of it had nothing to do with morphology. We will also have occasion to discuss the parallel disappearance of the CPC, another educational exercise in uncertainty that depended on autopsies. Accompanying the devaluation of the autopsy in the curriculum has been a shift in focus from the patient as an ill person to the illness, per se, at a cellular and molecular level. The latter has come to represent, in the eyes of many, “hard” science, while anything more global is criticized as too diffuse. Much has been lost in this shuffle, especially the opportunity to learn how to approach an unfamiliar problem 131
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failure is more unequivocal than death.” Thus, death dooms not only the patient, but also the physician. Some remarks by a surgery resident capture these feelings especially well. “I was getting a report from the surgical resident who had been on call the previous shift. ‘We had quite a time with your patient. . . ‘, he said. ‘She survived the operation, but I think she’ll probably die sometime today.’ ‘Not on my shift,’ I blurted without thinking . . . It was inevitable that the patient would die, but to let that person die on your shift was a sign of failure.“g The proclivity of physicians to view medical death as failure is not new,‘* but appears to have intensified markedly during the past 10 to 20 years. The threat of malpractice litigation has been implicated, but we wonder if it is being used, at least in part, as a socially acceptable facade. It sounds more professionally tough, even “macho,” to admit to concerns regarding a possible malpractice suit than to confess to overwhelming feelings of guilt and failure after the death of a patient. Pathologists subspecialize in the enlightened management of failure, including death, but, in general, have been curiously passive in insuring that this body of knowledge and understanding is transmitted to students and house staff. It is no longer widely accepted that the death of a patient creates an opportunity to learn. The CPC has gone the way of the autopsy. That exercise, in which large audiences assembled to watch an expert diagnostician grapple with a difficult case, is virtually extinct. Each week, the auditoriums of our medical schools were filled with students, house staff, and faculty who were full of anticipation, participated vigorously, sometimes argumentatively in the analysis of the case, exulted in the triumphs, and learned from the failures. Most CPCs were structured around a patient in whom autopsy had been particularly revealing. Thus, the focus was primarily on a person who had died. Death today, on the other hand, is viewed as failure and it is no longer deemed valuable to dissect failures in hopes of learning something of value; that weekly reminder of death and medical uncertainty, the CPC, is not popular. The above comments are reflected in the shift in emphasis of the CPC published weekly since 1923 in the New England Journal of Medicine. In a recent letter to the editor, Cohen and Schiff” noted a marked decline in the proportion of cases that used the autopsy to establish the diagnosis of record. In reply, Scully” mentioned several factors responsible for this change: (1) a decline in the number of autopsies performed at Massachusetts General Hospital; (2) increased use of new sampling techniques, combined with more sophisticated analysis, that permits early diagnosis and appropriate therapy; and (3) a decision “to schedule such cases for discussion while they are current rather than delay them for a year or sometimes longer until the patient has died.” Whatever the reasons, the decline reported by Cohen and Schiff’ I is dramatic: in 1965, 83% of cases relied on the autopsy; in 1970,65%; in 1975,31%; and in 1980, 14%. Although Scully disputes the last figure,‘* there can 132
be no doubt regarding the trend. And there can be little or no question that the discussion of a living patient, with a working diagnosis based upon a biopsy or a serum specimen, conjures up an entirely different set of emotions and questions than the analysis of a dead individual whose diagnosis was definitely estabished at autopsy. Both approaches are important educational exercises, but neither can, or should, exclude the other. AVOIDANCE OF ERROR During the post-World War II era, medical educators gradually adopted a very peculiar view of science in medical practice. This distorted view has generated a cadre of medical students and young physicians who fail to understand the centrality of medical judgment in medical practice. Indeed, far too many have come to see medicine as a binary/digital profession: issues are black or white, right or wrong, malignant or benign, to operate or not to operate.3 Acceptance to medical school is based, in large measure, on being “right” in exams and aptitude tests. The curriculum in the first 2 years, more dense than it was when the above-quoted essay was written, has undergone repeated and intense prepackaging (“spoonfeeding” to some), and many traditional efforts leading to learning of professional attitudes, including grappling with medical uncertainty, have been forced out. Courses in bioethics that examine the theoretical or intellectual aspects are no substitute for reflective conversations with thoughtful veteran practitioners. The challenging ethical issues in medicine require considerable time for thought and discussion before one can begin to develop a mature professional/ medical philosophy. As such, they resist prepackaging. Logic suggests that it takes time to come to grips with medical uncertainty, physician fallibility, and death. Perhaps it is no accident that these topics serve to characterize the majority of a recently published collection of essays from the “Piece of My Mind” section of JAMA. I3 These poignant articles reveal a bevy of authors still attempting to resolve these issues in a painful search for personal equilibrium. The emphasis on “rightness” continues after medical school; as a house officer and physician, the recent graduate has difficulty in effectively coming to grips with the uncertainty that is, and always will be, inherent in the practice of medicine. Once in practice, the recently minted scientist/clinician engages in various evasive actions, most notably the ordering of increasingly large numbers of tests and procedures, in an effort to force shades of grey into an unequivocal black or a clear-cut white. ‘-L The feeling that modern medicine is so powerful that error is inadmissible is not to be shaken, even at the death of the patient. In a recent survey, chairmen of departments of medicine, surgery, and pathology were asked to rank reasons for the decline of the autopsy. Table 1 compares these opinions. All three groups list “the feeling among clinicians that every-
MEDICALUNCERTAINTYAND THE AUTOPSY [Anderson et al) TABLE 1. Reasons for Decline in Interest in the Autopsy: Comparison of Opinions of Pathologists Versus Surgeons/Internists Surgeons/Internists Keason Lack of interest on the part of pathologists Feeling among physicians that everything is known about the case Poor education of medical students and hou,x staf’f which carries over to the practitioner Fear of confronting relatives Fear of litigation on the part of the attending phy;sician (:hange in rehgmus or social mores Fear of “being wrong” I.ack of scientific- interest in buman disease * Percentage of respondents who ranked autopsy; the numbers in parentheses represent Reprinted with permission.”
Primary
Factor*
Pathologists Rank
Primary
Factor*
Rank
34% (16)
3
52% (181
3
54% (2.5)
I
71% 12.51
1
50% (“3) +
c>
59’1~ (i’l
I
”
27% (IS) 14%’ (7)
1 6
17% (6) 36’l ( 13)
6
1.5% (7)
:i
11%(3)
7
9% (4)
H
the indicated normalized
:3q II)
-!I’? 114) cil (“I
category as one of their top three principal reasons for I.he decline values to account for larger numbers of respcmses bv pathologists.
thing is known about the case” as their first choice to explain the decline.” This faith in the power and accuracy of “modern” medicine exists despite overwhelming evidence to the contrary. Many of the studies that detail the discrepancies between premortem and postmortem diagnoses have been reviewed.” We select just a few recent ones. III a study involving 32 community hospitals and academic medical centers, the rate of major discrepancies between premortem and postmortem diagnoses was 33%N.4 Another study found little overall change over the past 50 years in the likelihood that a premortem diagnosis would be correct.‘” Specifically, the latter study, based on published data from over 50,000 autopsies, showed that the sensitivity and specificity of premortem diagnostic efforts improved over time with some disorders (rheumatic heart disease, leukemia), deteriorated with others (pulmonary tuberculosis, peritonitis, carcinoma of the lung, gastric-peptic ulcer, gastric carcinoma, pulmonary embolism, carcinoma of the liver), and showed little, if any, sustained change in the remainder (primary cirrhosis of the liver, acute coronary thrombosis/acute cirrhosis of the liver, acute coronary thrombosis/acute myocardial infarction). Another study concerned with the possible impact of modern diagnostic technology on the accuracy of clinical diagnostics over three decades in a single hospital showed similar changes, but no overall gain.‘” These recent observations join a considerable literature in support of the fact that, at least among patients who die and undergo autopsy, there remains much to ble learned, and that concerned clinicians can continue to profit by a careful comparison of their premortem observations with the pathologists’ postmortem findings. Seventy-five years ago, the tools that the artist/ practitioner of medicine could bring to bear on a medical problem were limited: a thoughtful interview, a careful physical examination, a laboratory test or two, alnd an appreciation of the patient’s family and living circumstances, the latter derived from long
.i x 4 7
of the
years of association with that family. The artist/ practitioner tended to accept death as inevitable, and accepted as part of professional life the sharing with the patient and the patient’s family the fear of loss, helping them to understand the place that death holds in our lives, and trying to cope with the disruption and despair. This was part of practicing well. This is no longer true. In a survey of physician behavior, Tolle et alI7 found that only 6Yf of responding physicians reported that they routinely contacted the family after the death of a patient. Commenting on this sort of behavior in a personal memoir, IrvineI asks, “Does our behavior reflect the objective approach to patients that we learned in our training? Does it remind us of our own eventual death or of our professional failure? Or are we simply insensitive to family needs?” The author goes on to discount these reasons, and to implicate a failure on the part of physicians to understand the importance of their participation in the death process. “Somehow, we must come to realize that our responsibility does not end with the pronouncement of death.” The physician/ scientist of today recoils from death, an all too visible proof of uncertainty and failure. The current hospice movement constitutes an attempt to fill the void left by the departure of the physician/scientist from this emotionally charged arena. Although physicians are involved in the hospice movement, other medical professionals, especially nurses, have supplied most of the leadership and direct patient care. Further evidence that this is a function of recent events comes from a survey in 1984 of’ a group of respected pathologists who were asked., “Are ‘good’ physicians more likely to obtain postmortem permission than poor ones ?‘,I9 Most of the 127 respondents agreed that the characteristics of a good physician predict an interest in the autopsy (an opinion that is not newzo), but, significantly, many specifically noted that this applied most strongly to older physicians. With respect to persons graduating from medical school later than circa 1970, this relationship was not felt to apply! This younger group of scientific clini133
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cians seem to see the autopsy as a relic of an earlier, less quantitative era, an era rendered obsolete by sophisticated technology that permits one to perform a non-invasive axial autopsy prior to death, so to speak. CONCLUSION Uncertainty remains a major presence in medicine. Clinical diagnostic methods are far from perfect, the course of a disease often defies prediction, and the effectiveness of a given treatment varies unexpectedly from patient to patient. Error is an immutable component of the practice of medicine. Yet current forces in education and society mold the physician/scientist into a person who expects to achieve perfection. An anonymous reviewer of a paper submitted by two of us stated, “I do not accept that a certain level of error is acceptable.” Crosby has championed a standard of “zero errors”21 and Walker et alz2 state “ . . more accurate clinical and laboratory studies allow a precise pathologic diagnosis to be made before death.” This sort of wishful thinking cannot be taken seriously in the formulation of guidelines in the proper practice of medicine, yet it underscores the current degree of naivete in most, if not all, American medical schools. Educational programs and experiences such as the autopsy and the CPC, which provided much of the early experience in recognizing and coping with uncertainty, have all but disappeared from the curriculum. In their place, we find an unrealistic standard of zero defects-a mythical goal kept alive by both professional paranoia and social denial. No physician has ever practiced infallible medicine. Fortunately, most defects in medical practice are of limited consequence to the patient. Serious errors are found at autopsy among hospitalized patients, however; the rate is significant (20% to 33%) and has exhibited little overall change for at least three decades.16 This is the standard of current performance; it is not the goal. No physician knowingly sets out to make inaccurate diagnoses. But veteran clinicians understand the difference between a laudatory goal and a realistic standard of performance, and they use the autopsy to help move the latter in the direction of the former. Young physicians and students generally fail to make this distinction. They understand the goal but confuse it with the standard. The bind they find themselves in is predictable. They see error and uncertainty around themselves but have not been given the training to understand and deal with it. As a result, they tend to repress and deny its existence. And they erode and evade a related standard-the autopsy standard-because it only serves to rekindle the unresolved fires of uncertainty. In discussing the problems inherent in the present approaches to the improvement of quality of medical practice, Berwick2s notes, “ . . . practically no system of measurement-at least none that measures people’s performance-is robust enough to survive the fear of those who are measured. Most measure134
ment tools eventually come under the control of those studied and, in their fear, such people ask not what measurement can tell them, but rather how they can make it safe.” He continues, “fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to disaffection, distortion of information, and the loss of the chance to learn” (italics added). As an alternative, Berwick proposes an approach originally developed in the United States which he terms the “Theory of Continuous Improvement.” The Japanese term this approach k&en*” or the ongoing search for opportunities for all processes to improve. Berwick’s epigram captures the spirit perfectly. “Every defect is a treasure”‘g and is strongly reminiscent of the philosophy of great clinicians when they discovered a misdiagnosis at autopsy. “Still more instructive than diagnoses confirmed, however, were instances in which discrepancies arose. They gave Corvisart an opportunity of showing in masterly fashion how and why he had erred, and of explaining what was to be learned from these new observations.“25 In this discovery of imperfection lies the opportunity for improvement.23 It is ironic that whereas uncertainty was previously acknowledged and served, directly and indirectly, to promote autopsy practice, in 1989 the opposite situation pertains: discomfort regarding uncertainty is leading to various forms of defensive behavior and eroding the importance of the autopsy. Thus, it would appear that restoration of the autopsy to a strong position in medical education and clinical practice will require widespread changes in attitudes. The beginnings of such changes may already be evident in concerns regarding the “caring” part of medical care and the importance of “holistic” medicine. Respected voices in medicine are decrying the atrophy of the “occupational rituals” of the discipline.26 Perhaps the fact that several pathology departments have in the past several years reinstituted an autopsy requirement for their students6 is part of the same awareness. Whatever the influences and the exact timing, it is difficult to believe that the present situation will continue. The untoward consequences are too painful and involve too many constituencies, from students to their teachers and, most particularly, to their patients. The interests of society are best served by a careful mixture of the new and old. The molecular basis of disease is critical to our understanding of the science of medicine; the fallibility of medical practice and learning from our errors is critical to our appreciation of medical uncertainty. Pathology can and should be a leader championing both spheres of activity.
REFERENCES 1. Fox RC: The autopsy: Its place in the attitude-learning of second-year students, in Essays in Medical Sociology, Journeys Into the Field. New York. NY, Wiley, 1979. pp 51-77 2. Fox RC: Training for uncertainty, in Merton RK, Reader CC, Kendall PL (eds): The Student-Physician. Cambridge, MA, Harvard University Press, 1957, pp 207-241
MEDICAL UNCERTAINTY AND THE AUTOPSY (Anderson et al)
3. Hill KB. Anderson RE: The Autopsy-Medical Practice and Public Policy. Stoneham. MA, Bucterworth, 1988 4. Battie RM, Pathak D, Humble G, et al: Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA 258:339-344. 198; .5. Liebow A.4: The autopsy room as a hall of.learning. Am J Med 2 1:485-4X6. 1956 6. Anderson RE. Hill RB: The current status of the autopsy in academic medical centers in the United States. Pathology Patterns, a biannual supplement to Am J Clin Pathol, 92:j31-537. 1989 7. Middleton WS: William Osler and the Blocklev dead house. ,] Okla State Med Assoc 69:387-397, 1976 8. Schulz R. Aderman D: How the medical staff copes with dying patients: A critical review. Omega 7: 1 l-21. 1976 9. Crosby 1: Not on my shift. in Dan BB, Young RK (eds): A Piece of My Mind. A Collection of Essays From The Journal of the American Medical Association. Los Angeles, CA, Feeling Fine Programs. 1988. pp 42-43 10. Fox RC:. Swazey JP: The Courage to Fail: A Social View of. Organ Transplants and Dialysis. Chicago, IL. University of Chitago Press, 1974 11. Cohen M, Schiff G: Declining rdte of autopsies. N Engl J hfed 310:1266. 1984 (letter) 12. Scully RE: Declining rate of autopsies. N kugl J Med Y 10: 1266. 1984 (letler) 13. Dan BB. Young RK (eds): A Piece of My Mind. A Collectlon of Essays From The Journal of the American Medical Association. Los Angeles, CA, Feeling Fine Programs, 1988
14. Kassirer JP: Our stubborn quest for diagnostic certainty: A cause of excessive testing. N Engl J Med 320: 1489-1491, 1989 15. Anderson RE, Hill RB. Kev CR: The sensitivit? and specificity,of clinical diagnostics over 5 decades: Toward an understandmg of necessary fallibility. JAMA 26 1: 161O- 16 17. 1989 16. Goldman L, Sayson R, Robbins S. et al: The value of the autopsy in three medical eras. N Engl J Med 308: IOOO- 1005, 1983 17. Tolle SW. Elliott DL. Hickam DH: Physrcian attitudes and practices at the time of patient death. Arch Intern Med 144:23X92391, 1984 IX. Irvine P: The attending dt the funeral N Engl J Med :~12:1704-1705. 1985 19. .4nderson RE: The autopsy as an instrument of qualit! assessment. Arch Pathol Lab Med 10X:490-493. I984 20. MacEachern MT: More autopsies: The) are vital to medical progress. Hospitals 2ti:58-60, 146. 1952 21. Crosb) PB: Quality Wirhout Tears. Sew Iork. NY. Mc(;raw-Hill, 1984 22. Walker AE. Robins M, Weinf’eld FD: Clinical findings, in Weinfeld FD (ed): The National Survev of Stroke. Stroke 12:13-31. I98 1 (suppl I) 23. Berwick DM: Continuous improvement as an ideal in health care. N Engl j Mecl 320:53-56, i989 24. Imai M: K&en: The Kev to laoanese (Zom~etitive Success. New York. NY, Random Ho;lse. i’YA6 25. Sigerist HE: The Great Doctors. (&den (:ity, NY, Dollbleday. 19.50 26. Bosk CL: Occupational rituals in patient management. N Engl,J Med 303:71-76. 1980
The role of the autopsy in helping medical students learn to accept and cope with the uncertainty inherent in the practice of medicine was extensively explored by one of the authors (R.C.F.) as a part of her studies concerning the sociology of medical education, conducted by the Bureau of Applied Social Research of Columbia University, in the mid-1950s.’ At that time, autopsy practice was in its heyday in the United States: over 50% of patients dying in hospitals in the United States underwent autopsy; physicians and students were in attendance at virtually every autopsy; autopsy-derived information was used to educate groups of physicians by clinical-pathologic conferences (CPCs), published reports, etc; and the catalog of diseases, as well as the very definition of disease, was learned by medical students from autopsy studies during medical school. Prior to the study referred to above, however, few educators had recognized the value of the autopsy in introducing students to the phenomenon of medical uncertainty.2 The other two authors of this report came across these studies while attempting to understand the surprisingly high rate of discrepancies regularly found between diagnoses made premortem by clinicians and those made postmortem by pathologists at autopsy.gs4
The mixing of the concepts of the autopsy as training for uncertainty and as the proof of uncertainty inherent in medical diagnostics led to an interesting exchange of ideas and opinions among the three of us. The distillate of these discussions forms the basis of this presentation. We start by reproducing portions of the early essay,’ since it is still apt and not well-known to physicians.* “This essay examines an event experienced by all second-year students at a medical college: the first autopsy they attend as part of their course in general pathology. It begins with the premise, shared by many medical educators, that the autopsy room is one of the important ‘halls of learning’5 in which medical students are trained to be physicians, and it goes on to suggest that the experience of the autopsy serves to transmit to students, in ways planned and unplanned, some of the attitudes and values, as well as knowledge and skills, required for the effective performance of the role of physician.” The author included an exploration of the autopsy experience as an aid to developing scientific detachment in the face of events with major emotional impact. Students often “make a self-conscious effort to enhance their objectivity by deliberately focusing on (the) scientific aspects.” The behavior of the prosector, “impersonal, matter-of-course,” provides a role model. TRAINING FOR UNCERTAINTY “The zautopsy plays a major role in training students for uncertainty, the process by which students learn about some of the uncertainties of medicine and develop ways of coping with them.“* KINDS OF UNCERTAINTY IN THE AUTOPSY
From the Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM: Department of Sociology, University of Pennsylvania, School of Arts and Sciences, Philadelphia, PA; and the Department of Pathology, State University of New York, Health Science Center, Syracuse, NY. Key won&: uncertainty, medical error, autopsy, medical education. Address reprint requests to Robert E. Anderson, MD, Department of Pathology. University of New Mexico School of Medicine, Albuquerque, NM 87 13 1. 0 1990 by W.B. Saunders Company. 0046-8 177/90/2102-0002$5.00/O
“Every doctor encounters three basic types of uncertainty: uncertainty that derives from limits on the state of medical knowledge; uncertainty that grows out of his imperfect mastery of all that is known; and
*Fox RC: The autopsy: Its place in the attitude-learning of second-year students, in Essays in Medical Sociology, Journeys Into the Field. Copyright 0 1979 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons.
428
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uncertaintv over how to distinguish between his own ignorance or ineptitude and the restricted powers of medicine itself, Second-year students are exposed simultaneously to all three kinds of uncertainty when they take part in autopsies. Since an autopsy is an organized attempt of pathologists and clinicians to resolve some of the uncertainties of a case by conducting a postmortem examination, students are also being introduced to one of the institutionalized ways in which physicians in a teaching and research center deal with uncertainty. Finally, the autopsy tests and advances the ability of students to come to terms with uncertaintv. “Panicipation in an autopsy makes students nlore aware in various ways of the uncertainties that result from limited medical knowledge. To begin with, being put on call for an autopsy reminds them that even when death is expected, the exact time of death is sleldom predictable. “Students become impressed by the limitations of current medical knowledge when they see that the autopsy-.the final and presumably exhaustive examination of the patient-often fails to tell what was the cause of the patient’s death. Even when the autopsy provides an answer, it is often less ‘dramatic’ and ‘specific’ than students expected it to be:
upon students during their participation in an autopsy. For example, the autopsy gives students an opportunity to observe that ‘the doctors aren’t always sure what caused the patient’s death’ or whether they could have done something to forestall it. As one student puts it, ‘they come to the autopsv to find [these things] out:’ “Students may be present at an autopsy in which it becomes apparent that the phvsician was mistaken in his medical judgments: My roommate had his autopsy l.nst week. And there were lots of things supposed to be wrong with this case. Well, as you know, the \.arious doctors who were involved in the case wander down white the autopsy is going on, and come in to see what was wrong with the patient. In my roommate’s case, they just weren’t finding anything in the doctor’s diagnoses “From experiences such as these, students may learn that because ‘medical knowledge is so vast’ and ‘there’s always so much to be taken into account, even the finest phvsicians’ do not command all the available informaiion relevant to each case they handle. Their medical knowledge, of course, is greater and more seasoned than that of medical students. But students have an opportunity to see in the autopsy that, nevertheless, mature physicians--like the students themselves -are confronted with uncertainties of diagnosis, therapy, and prognosis that grow out of their imperfect mastery of all there is to know in medicine. What is more, students can observe that lack of knowledge and its attendant uncertainty may have led ‘the best of doctors’ to misjudge a case. or to have ‘made mistakes’ that sometimes affected the welfare of the patient. “The third type of uncertainty the autopsy presents students derives from the first two: uncertainty over how to tell where the personal limitations of physicians leave off and the limitations of medical science begin. This is the kind of uncertaintv that an autopsy ought ideally to resolve. If the cl&icians could not make a diagnosis in a specific case. or failed to make a correct one, should they have been able to? Did they make the right therapeutic decisions? In short, given the current state of medical knowledge, could the death of the patient have been prevented? Unless unusual circumstances surround a case, such as the possibility that the patient’s death was due 1.0 ‘unnatural’ causes, or that some form of malpractice was involved, the pathologist who conducts the autopsy does not explicitly address himself to these questions. Nevertheless, they are always implicit in his postmortem examination. “The pathologist is often unable to answer some of the questions that were left unsolved by clinicians. When this is the case, it is generally because of the limitations of current medical knowledge rather than the ignorance or ineptitude of the clincians responsible for the case. But, . . . at some autopsies that students attend the pathologist is able to clear up some of the diagnostic and therapeutic uncertainties that
While our case was unusual, it was a bit of a letdown to me. f’or there was nothing dramatic to be pointed IO as the cause of death. The clinician reported that the patient had lost 1000~~. of blood from internal bleeding in the (2.1. tract. Well. we saw no gaping hole there. There was no one place you could pinpoint and say: “This is where the hemorrhage took place.” of a condition relating . . Kather, it was a culmination to various factors. I suppose most causes of death are this way. But still it was somewhat disquieting to me. “The extent of uncertainty at the end of an autopsy is often greater than students had anticipated. As a result, stlldents sometimes have difficulty in determining when the autopsy is over: I didn’t know the autopsy was over until I was told that it was. After going over each of the organs, Dr. L. continued to cut and to take pictures. Finally. at a certain point he had to tell us, “I guess that just about does it. YOU can go now.” But there’s really no finite point. You can’t say it ends here. “No matter how definitive an understanding of the ‘causes of the patient’s death’ that emerges from the autopsy, it remains obvious that physicians did not know how to prevent his death. This is conveyed to students primarily through the presence of various doctors connected with the case in the autopsy room and by the doctors’ discussions with the pathologist. In this way, stuclents become increasingly aware of another limitation in the field of medicine: its lack of control over death and the uncertainty with which physicians are confronted as a result of this limitation. “Not only the limits of the field, but the relationship between the personal limitations of physicians and the uncertainties they face become impressed 129
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clinicians left unsettled; in others, the findings of the pathologist contradict those previously arrived at by clinicians. When the latter happens, students may at first regard it as proof of the clinicians’ inadequacy in handling the case. But in many instances, the pathologist helps them see that ‘it is not as cut and dried as all that’: In the first autopsy I did with students this year, [a pathologist told us], the man was diagnosed as having a carcinoma of the stomach. During the course of the work-up on the patient, he suddenly died. It turned out that the pain in the patient’s stomach was not in the stomach, but in the liver. And what the patient died of was a tumor of the lung that was completely unsuspected. The students’ first reaction to this was, “what a ‘boo-boo’ on the part of the clinician!” What I did was say, “Here’s the chest x-ray done on the patient. Now you show me the cancer.” . Which they couldn’t. It wasn’t that visible. . . [I also tell students that] we try to write the autopsy up in such a way that doesn’t say, “Nyah, nyah, it was your fault.” Because it’s usually not as cut and dried as all that. “Students who assist a prosector with this point of view learn directly from him that it is often hard to distinguish between the ‘fault’ of the doctor and the ‘fault’ of the field of medicine.
“In sum, students learn from their first autopsies that, although death is inevitable, it presents physicians with several kinds of uncertainty that even a postmortem examination cannot always dispel. As we have seen, students react to these uncertainties with and chagrin. The realization surprise, discomfort, that death is something the doctor can neither ‘pinpoint’ nor easily prevent becomes especially ‘disquieting’ and ‘disappointing’ to them. On the whole, however, students seem able to cope successfully with the uncertainties presented by the autopsy.” BASIS OF COPING WITH UNCERTAINTY “By the time they are put on call for their first autopsy, second-year students have already had much * For one thing, even when training for uncertainty. they were freshmen, students were ‘given the major responsibility for learning’. In the non-spoonfeeding milieu of the first year at some medical schools . . information is not presented to them ‘in neat packets’; precise boundaries are not set on the amount of work expected of them; and they may not receive grades. Students have to find out for themselves how much they are expected to know, what they should learn, how they should go about it, and how well they are doing. Insofar as it teaches students to take responsibility in a relatively undefined situation, the non-spoon-feeding approach of their first year can be thought of as providing them with a foretaste of the ambiguities a physician encounters when he assumes responsibility for a patient. “First-year anatomy gave students their beginning awareness of the specific kind of uncertainty
that results from personal limitation. The venerable science of anatomy represents such a huge body of facts that, no matter how much time and energy they devoted to it, students found that they were unable to master all this knowledge. This experience helped students to see more clearly that they would always be faced with uncertainties derived from their inability to ‘know all there is to know.’ “Their course in pharmacology confronted students with the kind of uncertainty that stemmed from limitations of current medical knowledge. Pharmacology is a relatively tentative science . . . of experimentation. The study of pharmacology helped students to realize that not all the gaps in their knowledge indicated personal deficiencies. “Chiefly through their training in observation, students were also introduced to another kind of uncertainty before they assisted in their first autopsy. On the many occasions when they had trouble making some of the observations that their courses required of them (for example, visualizing anatomical entities or seeing what they were ‘supposed’ to be on a histological slide), they did not find it easy to decide how much of their difficulty was ‘personal’ and how much of it ‘had to do with factors outside [themselves].’ Their uncertainty was that of how to distinguish between their own limitations and those of medical knowledge itself. “Although the autopsy may be unique in exposing them simultaneously to all these types of uncertainty, students have had some prior experience with each type. “The ‘spirit’ in which they see pathologists and clinicians approach the autopsy also helps students to cope with these uncertainties. Students note that, in general, pathologists and clinicians at an autopsy freely acknowledge their uncertainties about the diagnosis and treatment of the case they are considering. (In fact, the autopsy is premised on their mutual willingness to do so, in order to learn from those uncertainties and thereby possibly to resolve some of them.) Because it gives students a chance to see mature scientists and physicians handle uncertainty in an open, affirmative way, the autopsy helps students to come to terms with their own uncertainties. It encourages them to accept their own uncertainty-to define some of it as ‘inevitable’ and ‘thoroughly legitimate’and to begin to cope with it by freely expressing that they are unsure. “Finally, the strains to which the uncertainties of the autopsy subject students are offset to some extent by these uncertainties deepening their scientific interest in the case
being
examined:
. . . Before the autopsy even began, you could tell from the clinical record that they hadn’t been too sure of what was wrong with the patient. In a way, I was hoping it wouldn’t be a clear-cut case. . Because it wasn’t clear-cut, it gave me a real desire to see the autopsy and try to find out what had really been the matter. I guess that’s one of the reasons why the emotional aspects of it were obscured. . There was the 130
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excitement of expecting one thing and finding another, and also many small things that hadn’t been anticipated.
concerned with disease and to anticipate the attendant alterations in homeostatic mechanisms. These changes have not been limited to pathology, and have led to the deemphasis of many of the more intimate, albeit time-consuming, medical student experiences -such as learning effective interviewing techniques and honing skills in physical diagnosis--in addition to the autopsy: These changes in the curriculum, resulting in conslderable diminution in the opportunities for students to undergo experiences in medical uncertainty. have been partly the result of changes in attitudes, and have in turn reinforced those additudinal changes. As a consequence, however, we run the risk of generating physicians who tail to understand that the science of medicine is highly inexact and that traditional approaches, including learning from one’s mistakes via the autopsy, have ongoing value.
“In sum, the autopsy presents students with various kinds of uncertainty and helps them to cope with each kind. It makes students more nearly aware that some of their uncertainty does not differ from that facing doctors and that candor about such uncertainties is expected and approved. This realization, along with their prctvious experiences with uncertainty and rheir intellectual attraction to cases that have some elements of unexpectedness, seem to enable students to come to terms with the uncertainties of the autopsy.” The essay concludes with short discussions of the role of the autopsy in providing training in the management of time, medical morality, and professional self-image and declares that “the first autopsy is a ‘rite de passage,’ a ‘landmark’ or ‘milestone’ event along the road to becoming a doctor that attitudinatty and symbolically incorporates students more fultv into the profession.” We will now expand the discussion of medical uncertainty and the autopsy, particularly with respect to the impact on medical students, in light of the evolutionary changes that have transpired in the 30 )ears since the above essay was written. We will be particularly concerned with the plummeting autopsy rate, some of‘ the reasons for that decline based on perceptioms of medical uncertainty, and some of the results of the decline, especially on medical education.
AUTOPSY AS CONTtNUtNG EDUCATtON For the physicians who arc the students’ teachers and role models, use of the autopsy to rleveal errors in medical care was a matter of acknowledged importance for many decades. Prior to the second half of the 20th century, the autopsy had contributed much of the scientific basis for the practice of medicine. The best clinicians, although understandably proud of their clinical acumen, freely acknowledged the limits of their knowledge, and looked to the findings from autopsies to help liberate them from their ignorance. A story about William Osler illustrates this attitude. Osler once had a patient “whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. I)r Osler seemed delighted, sent especially for all those in his ward classes: showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it.“; The physicians brought their students to the autopsy room, where the latter not only learned about disease, but listened to their mentors discussing errors in medical care with the pathologist. as described by Fox.’ Physicians expected themselves, their peers, and their students to learn, and to profit, from their mistakes. That mistakes were inevitable was universally accepted. The autopsy represented a unique opportunity to expand simultaneously the scientific basis of medicine, the knowledge of the students of the discipline, and the experience of the individual physician, as well as the chance to learn from errors. Today, the emphasis seems to have shifted. Many physicians seem more intent on hitting from, or otherwise avoiding, their mistakes than in learning from them. ‘l’he understanding that errors are an inevitable consequence of patient-physician interactions and that one can learn from one’s errors has given way to the unfortunate misconception that errors constitute such a failure as to be virtuallv inadmissible. And no
AUTOPSY IN THE MEDtCAL CURRtCULUM When the above article was written, the autopsy was a central part of the medical curriculum in most medical schools in the United States. By contrast, a recent survey of US academic departments of pathology revealed that less than half (42%‘) require that their students participate in an autopsy and, even in departments in which there were such requirements, the number of cases rarely exceeded one.” 1t is difficult to conceive how one case in isolation could accomplish the many values noted in the paper quoted above. One need only to remember that first autopsy experience, and the plethora of new feelings and stimuli, to understand that while much was learned, most of it had nothing to do with morphology. We will also have occasion to discuss the parallel disappearance of the CPC, another educational exercise in uncertainty that depended on autopsies. Accompanying the devaluation of the autopsy in the curriculum has been a shift in focus from the patient as an ill person to the illness, per se, at a cellular and molecular level. The latter has come to represent, in the eyes of many, “hard” science, while anything more global is criticized as too diffuse. Much has been lost in this shuffle, especially the opportunity to learn how to approach an unfamiliar problem 131
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failure is more unequivocal than death.” Thus, death dooms not only the patient, but also the physician. Some remarks by a surgery resident capture these feelings especially well. “I was getting a report from the surgical resident who had been on call the previous shift. ‘We had quite a time with your patient. . . ‘, he said. ‘She survived the operation, but I think she’ll probably die sometime today.’ ‘Not on my shift,’ I blurted without thinking . . . It was inevitable that the patient would die, but to let that person die on your shift was a sign of failure.“g The proclivity of physicians to view medical death as failure is not new,‘* but appears to have intensified markedly during the past 10 to 20 years. The threat of malpractice litigation has been implicated, but we wonder if it is being used, at least in part, as a socially acceptable facade. It sounds more professionally tough, even “macho,” to admit to concerns regarding a possible malpractice suit than to confess to overwhelming feelings of guilt and failure after the death of a patient. Pathologists subspecialize in the enlightened management of failure, including death, but, in general, have been curiously passive in insuring that this body of knowledge and understanding is transmitted to students and house staff. It is no longer widely accepted that the death of a patient creates an opportunity to learn. The CPC has gone the way of the autopsy. That exercise, in which large audiences assembled to watch an expert diagnostician grapple with a difficult case, is virtually extinct. Each week, the auditoriums of our medical schools were filled with students, house staff, and faculty who were full of anticipation, participated vigorously, sometimes argumentatively in the analysis of the case, exulted in the triumphs, and learned from the failures. Most CPCs were structured around a patient in whom autopsy had been particularly revealing. Thus, the focus was primarily on a person who had died. Death today, on the other hand, is viewed as failure and it is no longer deemed valuable to dissect failures in hopes of learning something of value; that weekly reminder of death and medical uncertainty, the CPC, is not popular. The above comments are reflected in the shift in emphasis of the CPC published weekly since 1923 in the New England Journal of Medicine. In a recent letter to the editor, Cohen and Schiff” noted a marked decline in the proportion of cases that used the autopsy to establish the diagnosis of record. In reply, Scully” mentioned several factors responsible for this change: (1) a decline in the number of autopsies performed at Massachusetts General Hospital; (2) increased use of new sampling techniques, combined with more sophisticated analysis, that permits early diagnosis and appropriate therapy; and (3) a decision “to schedule such cases for discussion while they are current rather than delay them for a year or sometimes longer until the patient has died.” Whatever the reasons, the decline reported by Cohen and Schiff’ I is dramatic: in 1965, 83% of cases relied on the autopsy; in 1970,65%; in 1975,31%; and in 1980, 14%. Although Scully disputes the last figure,‘* there can 132
be no doubt regarding the trend. And there can be little or no question that the discussion of a living patient, with a working diagnosis based upon a biopsy or a serum specimen, conjures up an entirely different set of emotions and questions than the analysis of a dead individual whose diagnosis was definitely estabished at autopsy. Both approaches are important educational exercises, but neither can, or should, exclude the other. AVOIDANCE OF ERROR During the post-World War II era, medical educators gradually adopted a very peculiar view of science in medical practice. This distorted view has generated a cadre of medical students and young physicians who fail to understand the centrality of medical judgment in medical practice. Indeed, far too many have come to see medicine as a binary/digital profession: issues are black or white, right or wrong, malignant or benign, to operate or not to operate.3 Acceptance to medical school is based, in large measure, on being “right” in exams and aptitude tests. The curriculum in the first 2 years, more dense than it was when the above-quoted essay was written, has undergone repeated and intense prepackaging (“spoonfeeding” to some), and many traditional efforts leading to learning of professional attitudes, including grappling with medical uncertainty, have been forced out. Courses in bioethics that examine the theoretical or intellectual aspects are no substitute for reflective conversations with thoughtful veteran practitioners. The challenging ethical issues in medicine require considerable time for thought and discussion before one can begin to develop a mature professional/ medical philosophy. As such, they resist prepackaging. Logic suggests that it takes time to come to grips with medical uncertainty, physician fallibility, and death. Perhaps it is no accident that these topics serve to characterize the majority of a recently published collection of essays from the “Piece of My Mind” section of JAMA. I3 These poignant articles reveal a bevy of authors still attempting to resolve these issues in a painful search for personal equilibrium. The emphasis on “rightness” continues after medical school; as a house officer and physician, the recent graduate has difficulty in effectively coming to grips with the uncertainty that is, and always will be, inherent in the practice of medicine. Once in practice, the recently minted scientist/clinician engages in various evasive actions, most notably the ordering of increasingly large numbers of tests and procedures, in an effort to force shades of grey into an unequivocal black or a clear-cut white. ‘-L The feeling that modern medicine is so powerful that error is inadmissible is not to be shaken, even at the death of the patient. In a recent survey, chairmen of departments of medicine, surgery, and pathology were asked to rank reasons for the decline of the autopsy. Table 1 compares these opinions. All three groups list “the feeling among clinicians that every-
MEDICALUNCERTAINTYAND THE AUTOPSY [Anderson et al) TABLE 1. Reasons for Decline in Interest in the Autopsy: Comparison of Opinions of Pathologists Versus Surgeons/Internists Surgeons/Internists Keason Lack of interest on the part of pathologists Feeling among physicians that everything is known about the case Poor education of medical students and hou,x staf’f which carries over to the practitioner Fear of confronting relatives Fear of litigation on the part of the attending phy;sician (:hange in rehgmus or social mores Fear of “being wrong” I.ack of scientific- interest in buman disease * Percentage of respondents who ranked autopsy; the numbers in parentheses represent Reprinted with permission.”
Primary
Factor*
Pathologists Rank
Primary
Factor*
Rank
34% (16)
3
52% (181
3
54% (2.5)
I
71% 12.51
1
50% (“3) +
c>
59’1~ (i’l
I
”
27% (IS) 14%’ (7)
1 6
17% (6) 36’l ( 13)
6
1.5% (7)
:i
11%(3)
7
9% (4)
H
the indicated normalized
:3q II)
-!I’? 114) cil (“I
category as one of their top three principal reasons for I.he decline values to account for larger numbers of respcmses bv pathologists.
thing is known about the case” as their first choice to explain the decline.” This faith in the power and accuracy of “modern” medicine exists despite overwhelming evidence to the contrary. Many of the studies that detail the discrepancies between premortem and postmortem diagnoses have been reviewed.” We select just a few recent ones. III a study involving 32 community hospitals and academic medical centers, the rate of major discrepancies between premortem and postmortem diagnoses was 33%N.4 Another study found little overall change over the past 50 years in the likelihood that a premortem diagnosis would be correct.‘” Specifically, the latter study, based on published data from over 50,000 autopsies, showed that the sensitivity and specificity of premortem diagnostic efforts improved over time with some disorders (rheumatic heart disease, leukemia), deteriorated with others (pulmonary tuberculosis, peritonitis, carcinoma of the lung, gastric-peptic ulcer, gastric carcinoma, pulmonary embolism, carcinoma of the liver), and showed little, if any, sustained change in the remainder (primary cirrhosis of the liver, acute coronary thrombosis/acute cirrhosis of the liver, acute coronary thrombosis/acute myocardial infarction). Another study concerned with the possible impact of modern diagnostic technology on the accuracy of clinical diagnostics over three decades in a single hospital showed similar changes, but no overall gain.‘” These recent observations join a considerable literature in support of the fact that, at least among patients who die and undergo autopsy, there remains much to ble learned, and that concerned clinicians can continue to profit by a careful comparison of their premortem observations with the pathologists’ postmortem findings. Seventy-five years ago, the tools that the artist/ practitioner of medicine could bring to bear on a medical problem were limited: a thoughtful interview, a careful physical examination, a laboratory test or two, alnd an appreciation of the patient’s family and living circumstances, the latter derived from long
.i x 4 7
of the
years of association with that family. The artist/ practitioner tended to accept death as inevitable, and accepted as part of professional life the sharing with the patient and the patient’s family the fear of loss, helping them to understand the place that death holds in our lives, and trying to cope with the disruption and despair. This was part of practicing well. This is no longer true. In a survey of physician behavior, Tolle et alI7 found that only 6Yf of responding physicians reported that they routinely contacted the family after the death of a patient. Commenting on this sort of behavior in a personal memoir, IrvineI asks, “Does our behavior reflect the objective approach to patients that we learned in our training? Does it remind us of our own eventual death or of our professional failure? Or are we simply insensitive to family needs?” The author goes on to discount these reasons, and to implicate a failure on the part of physicians to understand the importance of their participation in the death process. “Somehow, we must come to realize that our responsibility does not end with the pronouncement of death.” The physician/ scientist of today recoils from death, an all too visible proof of uncertainty and failure. The current hospice movement constitutes an attempt to fill the void left by the departure of the physician/scientist from this emotionally charged arena. Although physicians are involved in the hospice movement, other medical professionals, especially nurses, have supplied most of the leadership and direct patient care. Further evidence that this is a function of recent events comes from a survey in 1984 of’ a group of respected pathologists who were asked., “Are ‘good’ physicians more likely to obtain postmortem permission than poor ones ?‘,I9 Most of the 127 respondents agreed that the characteristics of a good physician predict an interest in the autopsy (an opinion that is not newzo), but, significantly, many specifically noted that this applied most strongly to older physicians. With respect to persons graduating from medical school later than circa 1970, this relationship was not felt to apply! This younger group of scientific clini133
HUMAN PATHOLOGY
Volume 21, No. 2 (Februan/ 1990)
cians seem to see the autopsy as a relic of an earlier, less quantitative era, an era rendered obsolete by sophisticated technology that permits one to perform a non-invasive axial autopsy prior to death, so to speak. CONCLUSION Uncertainty remains a major presence in medicine. Clinical diagnostic methods are far from perfect, the course of a disease often defies prediction, and the effectiveness of a given treatment varies unexpectedly from patient to patient. Error is an immutable component of the practice of medicine. Yet current forces in education and society mold the physician/scientist into a person who expects to achieve perfection. An anonymous reviewer of a paper submitted by two of us stated, “I do not accept that a certain level of error is acceptable.” Crosby has championed a standard of “zero errors”21 and Walker et alz2 state “ . . more accurate clinical and laboratory studies allow a precise pathologic diagnosis to be made before death.” This sort of wishful thinking cannot be taken seriously in the formulation of guidelines in the proper practice of medicine, yet it underscores the current degree of naivete in most, if not all, American medical schools. Educational programs and experiences such as the autopsy and the CPC, which provided much of the early experience in recognizing and coping with uncertainty, have all but disappeared from the curriculum. In their place, we find an unrealistic standard of zero defects-a mythical goal kept alive by both professional paranoia and social denial. No physician has ever practiced infallible medicine. Fortunately, most defects in medical practice are of limited consequence to the patient. Serious errors are found at autopsy among hospitalized patients, however; the rate is significant (20% to 33%) and has exhibited little overall change for at least three decades.16 This is the standard of current performance; it is not the goal. No physician knowingly sets out to make inaccurate diagnoses. But veteran clinicians understand the difference between a laudatory goal and a realistic standard of performance, and they use the autopsy to help move the latter in the direction of the former. Young physicians and students generally fail to make this distinction. They understand the goal but confuse it with the standard. The bind they find themselves in is predictable. They see error and uncertainty around themselves but have not been given the training to understand and deal with it. As a result, they tend to repress and deny its existence. And they erode and evade a related standard-the autopsy standard-because it only serves to rekindle the unresolved fires of uncertainty. In discussing the problems inherent in the present approaches to the improvement of quality of medical practice, Berwick2s notes, “ . . . practically no system of measurement-at least none that measures people’s performance-is robust enough to survive the fear of those who are measured. Most measure134
ment tools eventually come under the control of those studied and, in their fear, such people ask not what measurement can tell them, but rather how they can make it safe.” He continues, “fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to disaffection, distortion of information, and the loss of the chance to learn” (italics added). As an alternative, Berwick proposes an approach originally developed in the United States which he terms the “Theory of Continuous Improvement.” The Japanese term this approach k&en*” or the ongoing search for opportunities for all processes to improve. Berwick’s epigram captures the spirit perfectly. “Every defect is a treasure”‘g and is strongly reminiscent of the philosophy of great clinicians when they discovered a misdiagnosis at autopsy. “Still more instructive than diagnoses confirmed, however, were instances in which discrepancies arose. They gave Corvisart an opportunity of showing in masterly fashion how and why he had erred, and of explaining what was to be learned from these new observations.“25 In this discovery of imperfection lies the opportunity for improvement.23 It is ironic that whereas uncertainty was previously acknowledged and served, directly and indirectly, to promote autopsy practice, in 1989 the opposite situation pertains: discomfort regarding uncertainty is leading to various forms of defensive behavior and eroding the importance of the autopsy. Thus, it would appear that restoration of the autopsy to a strong position in medical education and clinical practice will require widespread changes in attitudes. The beginnings of such changes may already be evident in concerns regarding the “caring” part of medical care and the importance of “holistic” medicine. Respected voices in medicine are decrying the atrophy of the “occupational rituals” of the discipline.26 Perhaps the fact that several pathology departments have in the past several years reinstituted an autopsy requirement for their students6 is part of the same awareness. Whatever the influences and the exact timing, it is difficult to believe that the present situation will continue. The untoward consequences are too painful and involve too many constituencies, from students to their teachers and, most particularly, to their patients. The interests of society are best served by a careful mixture of the new and old. The molecular basis of disease is critical to our understanding of the science of medicine; the fallibility of medical practice and learning from our errors is critical to our appreciation of medical uncertainty. Pathology can and should be a leader championing both spheres of activity.
REFERENCES 1. Fox RC: The autopsy: Its place in the attitude-learning of second-year students, in Essays in Medical Sociology, Journeys Into the Field. New York. NY, Wiley, 1979. pp 51-77 2. Fox RC: Training for uncertainty, in Merton RK, Reader CC, Kendall PL (eds): The Student-Physician. Cambridge, MA, Harvard University Press, 1957, pp 207-241
MEDICAL UNCERTAINTY AND THE AUTOPSY (Anderson et al)
3. Hill KB. Anderson RE: The Autopsy-Medical Practice and Public Policy. Stoneham. MA, Bucterworth, 1988 4. Battie RM, Pathak D, Humble G, et al: Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA 258:339-344. 198; .5. Liebow A.4: The autopsy room as a hall of.learning. Am J Med 2 1:485-4X6. 1956 6. Anderson RE. Hill RB: The current status of the autopsy in academic medical centers in the United States. Pathology Patterns, a biannual supplement to Am J Clin Pathol, 92:j31-537. 1989 7. Middleton WS: William Osler and the Blocklev dead house. ,] Okla State Med Assoc 69:387-397, 1976 8. Schulz R. Aderman D: How the medical staff copes with dying patients: A critical review. Omega 7: 1 l-21. 1976 9. Crosby 1: Not on my shift. in Dan BB, Young RK (eds): A Piece of My Mind. A Collection of Essays From The Journal of the American Medical Association. Los Angeles, CA, Feeling Fine Programs. 1988. pp 42-43 10. Fox RC:. Swazey JP: The Courage to Fail: A Social View of. Organ Transplants and Dialysis. Chicago, IL. University of Chitago Press, 1974 11. Cohen M, Schiff G: Declining rdte of autopsies. N Engl J hfed 310:1266. 1984 (letter) 12. Scully RE: Declining rate of autopsies. N kugl J Med Y 10: 1266. 1984 (letler) 13. Dan BB. Young RK (eds): A Piece of My Mind. A Collectlon of Essays From The Journal of the American Medical Association. Los Angeles, CA, Feeling Fine Programs, 1988
14. Kassirer JP: Our stubborn quest for diagnostic certainty: A cause of excessive testing. N Engl J Med 320: 1489-1491, 1989 15. Anderson RE, Hill RB. Kev CR: The sensitivit? and specificity,of clinical diagnostics over 5 decades: Toward an understandmg of necessary fallibility. JAMA 26 1: 161O- 16 17. 1989 16. Goldman L, Sayson R, Robbins S. et al: The value of the autopsy in three medical eras. N Engl J Med 308: IOOO- 1005, 1983 17. Tolle SW. Elliott DL. Hickam DH: Physrcian attitudes and practices at the time of patient death. Arch Intern Med 144:23X92391, 1984 IX. Irvine P: The attending dt the funeral N Engl J Med :~12:1704-1705. 1985 19. .4nderson RE: The autopsy as an instrument of qualit! assessment. Arch Pathol Lab Med 10X:490-493. I984 20. MacEachern MT: More autopsies: The) are vital to medical progress. Hospitals 2ti:58-60, 146. 1952 21. Crosb) PB: Quality Wirhout Tears. Sew Iork. NY. Mc(;raw-Hill, 1984 22. Walker AE. Robins M, Weinf’eld FD: Clinical findings, in Weinfeld FD (ed): The National Survev of Stroke. Stroke 12:13-31. I98 1 (suppl I) 23. Berwick DM: Continuous improvement as an ideal in health care. N Engl j Mecl 320:53-56, i989 24. Imai M: K&en: The Kev to laoanese (Zom~etitive Success. New York. NY, Random Ho;lse. i’YA6 25. Sigerist HE: The Great Doctors. (&den (:ity, NY, Dollbleday. 19.50 26. Bosk CL: Occupational rituals in patient management. N Engl,J Med 303:71-76. 1980