BMJ  2004;328:165-166 (17 January), doi:10.1136/bmj.328.7432.165-b

Letter

Death of the teaching autopsy

Advances in technology have not reduced the value of the autopsy

EDITOR—One of the proposed reasons for the death of the autopsy described by O'Grady is an increased confidence in new diagnostic tools, particularly modern imaging techniques.^{1 2} Surprisingly, the rate of misdiagnoses detected at autopsy (about 40%) did not improve from 1960-70, before the advent of computed tomography, ultrasound, nuclear scanning, etc, to 1980, after these technologies became widely used.³

In 2003, of 53 autopsy series identified, 42 reported major errors (clinically missed diagnoses involving a primary cause of death) and 37 reported class I errors (those most likely to have affected patient outcome).⁴ The median error rate was 23.5% (range 4.1%-49.8%) for major errors and 9.0% (0-20.7%) for class I errors.

Advances in imaging and diagnostic technology have not reduced the value of the autopsy. Autopsies could serve as indicators of overall performance of care systems over time or in comparison with other systems.⁵ Autopsies also have an important role in monitoring quality among populations with an increasing proportion of geriatric and obese patients with comorbidities.

Missed diagnoses detected at autopsy also have important implications for research. Medical records contain substantial inaccuracies on the principal diagnoses causing or contributing to death. These inacccuracies have important policy implications, as major funding and policy decisions are based in part on vital statistics and other estimates of disease burden.

Autopsy means to see for oneself. It would be as foolish to think we have reached the limits of human knowledge as it is to think we will some day know everything. There is always, and will ever be, scope for improvement, to learn from knowing when our certainties are simply wrong.

Department of Endocrinology, Medical School, University of Navarra, 31008 Pamplona, Spain gfruhbeck{at}unav.es

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Competing interests: None declared.

References

1. O'Grady G. Death of the teaching autopsy [with commentary by J Underwood]. BMJ 2003;327: 802-4. (4 October.)[Free Full Text]
2. Burton EC, Troxclair DA, Newman WP III. Autopsy diagnoses of malignant neoplasms. How often are clinical diagnoses incorrect? JAMA 1998;280: 1245-8.[Abstract/Free Full Text]
3. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med 1983;308: 1000-5.[Abstract]
4. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time. A systematic review. JAMA 2003;289: 2849-56.[Abstract/Free Full Text]
5. Lynn J, Cobbs E, Orenstein J. Autopsy rates and diagnosis. JAMA 1999;281: 2181.[Free Full Text]

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Death of the teaching autopsy

Gregory O'Grady
BMJ 2003 327: 802-803. [Extract] [Full Text] [PDF]

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