Monday, April 21, 2008
No More Black Box
While I've often wondered about emulating the airline industry, there is one innovation that single-handedly has determined the cause of many airline crashes: the on-board flight recorder, or "black box." Anytime there's a crash, it's what the recovery teams look for on land or the divers seek in the sea. It's the constant stream of retrospective data provided by the flight recorder that allows researchers analyze the conversations, wind conditions, air speed, aileron positions, altimeter recordings, and the like of a flight so the circumstances that lead to the ultimate catastrophe can be recreated. The data from the flight recorder has undeniably improved the airline industry's accident rates.
Regrettably, medicine is losing our black box: the autopsy.
Certainly, with the amazing advances in imaging, we have an unprecedented ability to peer inside the body with remarkable clarity to understand disease processes. Many argue that our understanding of events leading to the death of a patient are better defined than ever before - so why an autopsy?
One only needs to look at the multiple causes of a lung infiltrate on chest x-ray to understand what could be learned: was it caused by infection (bacterial, fungal, viral, worms?), or hemorrhage, or inflammation (bronchoalveolitis obliterans, sarcoid, amyloid, or many other causes), that this person died? Were we treating the correct diagnosis? Would management have been different had we known? Could future lives be saved by a better understanding of the precise cause of death of this one, unfortunate individual?
We will never know. But now we can consistently proclaim, "we did the best we could."
Gone are the days where a third year medical student can hold a heart in his or her hand, smell pseudomonas, see an occluded or anomalous coronary artery or aortic stenosis in person. In effect, medicine has lost the color of human reality in exchange for the black and white images on a monitor screen.
And where are the continuing quality improvement advocates in this debate? They're looking at the living and forgetting about the mistakes that are buried. Yes, Virginia, we do get it wrong sometimes but you'll never know now.
Unfortunately, autopsies are expensive: performed by pathologists who take samples, prepare slides and cultures, write detailed reports scrutinized by lawyers, and occasionally do high-tech tests like electron microscopy to define an answer. In our constant efforts to shave costs, the autopsy's "return" on investment to the education of future physicians is lost since the patient is already dead - another data point chalked up to "mortality." Death, then, has now officially lost its value to the future education of our physicians.
So as the dehumanization of medicine continues, rest in piece, Mr. Autopsy.
Us old farts in medicine will miss you.