Intended for healthcare professionals

Rapid response to:

Education And Debate

Death of the teaching autopsy

BMJ 2003; 327 doi: (Published 02 October 2003) Cite this as: BMJ 2003;327:802

Rapid Response:

The autopsy as a research tool versus the arrogance of twenty-first-century medicine

The moribund state of autopsies has been clearly established by
O'Grady (1). One of the proposed reasons for this circumstance is an
increased confidence in new diagnostic tools, particularly modern imaging
techniques (1, 2). Surprisingly, the rates at which misdiagnosis was
detected in autopsy studies (about 40%) had not improved from 1960 and
1970, before the advent of computerised tomography, ultrasound, nuclear
scanning, and other technologies, compared to 1980, after those
technologies became widely used (3). In 2003, the most recently published
systematic review on rates of autopsy-detected diagnostic errors, of 53
autopsy series identified, 42 reported major errors (i.e. 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%
(range: 0-20.7%) for class I errors. Advances in imaging and diagnostic
technology have not reduced the value of the autopsy. Goal-directed
autopsies should remain a vital element in the assurance of medical care
excellence. Moreover, autopsies could serve as indicators of overall
performance of care systems compared over time or among themselves (5).
For this purpose comparable methods should be applied to sample deaths in
health care systems with autopsies and chart reviews to assess quality
management, reasonable decision making and appropriateness of provided
care. Actually, autopsies are called to play an important role in
monitoring quality among a population with an increasing proportion of
geriatric and obese patients with polypathology and co-morbidity.

In addition to their intrinsic clinical interest, missed diagnoses
detected at autopsy may have important implications for research. Medical
records contain substantial inaccuracies regarding the principal diagnoses
causing or contributing to death. These inacccuracies have important
policy implications, as major funding and policy decisions derive in part
from vital statistics and other estimates of disease burden. By the turn
of the twentieth century Virchow, Rokitansky and Osler defended autopsies
as a research tool to prevent misdiagnoses. Once doctors had insured a
dignified and respectful dissection of the body relatives of the deceased
no longer viewed autopsies with suspicion. Autopsy literally 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.

1. O'Grady G. Death of the teaching autopsy. BMJ 2003;327:802-4.

2. Burton EC, Troxclair DA, Newman III WP. Autopsy diagnoses of
malignant neoplasms. How often are clinical diagnoses incorrect? JAMA

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

4. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates
of autopsy-detected diagnostic errors over time. A systematic review. JAMA

5. Lynn J, Cobbs E, Orenstein J. Autopsy rates and diagnosis. JAMA

Competing interests:
None declared

Competing interests: No competing interests

02 November 2003
Gema Frühbeck
Clinical Scientist
Dept. of Endocrinology, Clinica Universitaria de Navarra, Univ. of Navarra, 31008 Pamplona, Spain