OTHER CORRELATES OF THE DECLINE IN AUTOPSY RATE

Abstract

The decline in the autopsy rate (Horowitz RE. Autopsies: an exercise in futility? J R Coll Physicians Edinb 2009; 39:l94-5) might well be a manifestation of the increasing reliance on technological advances in imaging so as to arrive at a diagnosis. Although imaging techniques have led to huge improvements in the quality of healthcare, the paradox is that there has not been a corresponding improvement in the quality of the content of the undergraduate medical curriculum because the decline in autopsy rate has resulted in an atrophy of the skills of clinico-pathological correlation, the latter skills being ones traditionally taught in tandem with skills in eliciting physical signs.

Even bedside teaching of clinical skills is ‘unfortunately in steady decline’,¹ and it has now also become a ‘badge of honour’ to arrive at a diagnosis without the benefit of performing a clinical examination.² The latter development is a fortunate one for the National Health Service because in the new era of nurse-led consultations (a third of consultations in general practice in England in 2008 were with nurses³) it is much less labour-intensive to bypass the clinical examination altogether when teaching diagnostic skills to prospective nurse practitioners. Only in non-Western rural societies such as that in the Eastern Cape province in South Africa, where I practised medicine for seven years, was there an expectation among members of the public that the ingredients of the ‘complete package’ of a medical consultation should comprise, in this order, history taking, clinical examination, diagnosis (articulated in terms which the patient could understand) and treatment. Fortunately, highly sophisticated patients in the West have no such expectations when they attend clinics in primary as well as in secondary and tertiary care, where stripping down to the waist to have a full clinical examination has become increasingly anachronistic, thanks to the advent of high-tech imaging.

The ‘downside’ is the inappropriate use of laboratory tests and imaging, as shown in a study where ‘selecting tests based on history and [clinical] examination and prioritising less expensive and higher yield tests’ would have been more cost-effective.⁴ In that study postural blood pressure recording, performed in only 38% of episodes, had a higher yield with respect to affecting diagnosis and management and determining aetiology of the syncopal episode than head computed tomography scans, which were performed in as many as 63% of instances.⁴ The wastefulness (in this era of economic stringency) of bypassing the clinical examination is compounded by the scant respect with which the results of high-tech tests are themselves treated, exemplified by the traditional disorder prevailing in the health record, where ‘anything’ is filed ‘anywhere’ and ‘anyhow’,⁵ and no audit is made either of the quality and content record-keeping or of the quality and content of discharge summaries and clinic letters.