Faculty Bibliography

The number of autopsies being performed in the United States has fallen sharply in recent years, and many medical leaders are concerned that the quality of medical care is being jeopardized as a result. 'The situation in Minnesota probably mirrors the rest of the country,' said Dr. James Hansen of St. Cloud, immediate past president of the Minnesota Society of Clinical Pathologists. He said autopsies serve as a quality control measure for medicine, as well as advancing medical knowledge and education. But while more autopsies are needed, he said, 'you need to select the cases' where the findings are likely to be helpful. Experts are uncertain about the causes of the decline, but in 1970 it gained impetus when the Joint Commission on Accreditation of Healthcare Organizations decided to drop its requirement that hospitals perform autopsies in at least 20 percent of all deaths. The commission said at the time, 'No single rate for autopsies would be appropriate for all hospitals.'

''Many would have declared her dead at that point,'' said Dr. Howard W. Corneli, another pediatrician on the team. ''Other staff members thought Dr. [Robert G. Bolte] was crazy.'' ''Most important, the child was so profoundly cold,'' Dr. Bolte said. ''Also, we had a rough idea she had been under for about 45 minutes,'' the longest period from which anyone had ever recovered with their brain intact. If it had been much longer, he said he would have stopped. When [Michelle Funk]'s parents arrived, Dr. Bolte said, ''we told them the possible scenarios and that if we rewarmed the child there was a strong likelihood that she would have significant brain damage.'' Everyone decided ''to go for it because rewarming was her only chance,'' Dr. Bolte said

In citing one argument against such an effort, the accreditation commission said that when it required specific numbers of autopsies, hospitals performed them unselectively simply to satisfy the requirement. Some doctors were said to have intimidated families and to have misled grieving relatives by telling them that an autopsy might help clarify the cause of death when the diagnosis was clear. The plunge in autopsy rates, from about 50 percent of all deaths in the mid-1940s to 10 percent in 1985, began in the mid-1960s. Doctors are uncertain about the causes of the decline, but in 1970 it gained impetus when the Joint Commission on Accreditation of Healthcare Organizations decided to drop its requirement that hospitals perform autopsies in at least 20 percent of all deaths

Dr. Peter Kowey of the Medical College of Pennsylvania in Philadelphia wrote in the cardiology journal that 'the calamity of cardioversion of conscious patients' is occurring 'with alarming frequency.' He gave no numbers, and some other cardiologists insisted the number of cases is very small. But any such experience is 'alarming,' Kowey's editorial said. In non-emergency cases, drug treatments can sometimes serve in place of electrical cardioversion, Kowey and other experts said. But even in an emergency in which the procedure must be performed on a conscious patient, the doctors said anesthesia should be administered. In his editorial, Kowey argued that doctors need to prevent the 'psychological upheaval' that cardioversion causes in conscious, unanesthetized patients. Many patients who receive electrical cardioversion require long-term psychiatric consultation for the sleeplessness, nightmares, panic attacks, depression and agitation they experience, Kowey said. He added that fear of having to go through another cardioversion has impeded additional testing

One obvious example is Legionnaire's disease, which was identified when it struck members of the American Legion who met in Philadelphia in 1976. Researchers learned from the outbreak that the bacterial infection had long been an important cause of pneumonia throughout the world. Other ailments, like Cushing's syndrome (an overactive adrenal gland) and Wernicke's encephalopathy (brain damage due to alcohol toxicity and nutritional deficiency), were named to honor discoverers and leading physicians. Because antibiotic treatment for Lyme disease is most successful in the earlieqt stages of the illness, delays in diagnosis jeopardize chances for a cure

The plunge in autopsy rates, from about 50 percent of all deaths in the mid-1940's to 10 percent in 1985, began in the mid-1960's. Doctors are uncertain about the causes of the decline, but in 1970 it gained impetus when the Joint Commission on Accreditation of Healthcare Organizations decided to drop its requirement that hospitals perform autopsies in at least 20 percent of all deaths. The commission said at the time, ''No single rate for autopsies would be appropriate for all hospitals.'' Commission's New Policy Dr. [William Roper] said he was ''concerned about the decline in autopsies'' over recent years because ''they are a valuable part of the process of assuring quality medical care.'' Dr. Roper said it was easier for his agency to use a ''club'' approach, stipulating that hospitals do a specified number of autopsies, rather than the a ''sugar'' approach in which pathologists are paid for each autopsy because of the agency's philosophy that it ''buys a bundle of services for a fixed payment.'' He said his decision would be based on results of a study his staff is conducting

''There's a general climate of optimism with fewer people dying prematurely and many more leading productive lives,'' said Dr. Theodore M. Bayless, an expert in inflammatory bowel disease at Johns Hopkins Hospital in Baltimore. ''But you cannot minimize the impact of this chronic illness because it hits people at a critical time, often in their 20's, and puts a big burden on them.'' ''All these things help tremendously in improving the care and the outlook for the inflammatory bowel disease patient, and provide everyone with a lot more leeway in terms of what they can do,'' said Dr. Daniel H. Present, an expert on inflammatory bowel disease at Mount Sinai Medical Center in New York. Difficulty of Diagnosis Dr. Present, an author of the Mount Sinai study, said he was ''less enthusiastic'' about the development of 5-ASA treatments, and ''more excited'' by preliminary results of studies of three other drugs, cyclosporine, 6-MP and azathoprine

Picture the scene: A team of doctors has just identified a strange and apparently new form of arthritis that showed up in Lyme, Conn., and they want to name it appropriately. They decide to call it 'Lyme arthritis,' and thereby unwittingly manage to ensure a certain measure of confusion about that disease for years. Doctors name an ailment for the first place it is spotted or on other limited information, and then a new understanding of the disease renders the name obsolete and potentially misleading

Dr. Allen C. Steere Jr., who headed the Yale team that discovered the disease and called it Lyme arthritis, acknowledged the confusion. ''It seems that at every international symposium, we have had talks about the problem of the name of the disease,'' said Dr. Steere, who is now at Tufts-New England Medical Center in Boston. ''But no one has been able to come up with something better.'' ''The term 'AIDS' is obsolete,'' the Presidential commission on AIDS said in its report last month. ''HIV infection more correctly defines the problem.'' HIV, for human immunodeficiency virus, is the scientific name for the virus that causes the disease. ''The medical, public health, political and community leadership must focus on the full course of HIV infection rather than concentrating on later stages of the disease (ARC and AIDS),'' the commission said. ''Continual focus on AIDS rather than the entire spectrum of HIV disease has left our nation unable to deal adequately with the epidemic. Federal and state data collection efforts must now be focused on early HIV reports, while still collecting data on symptomatic disease.''

''We're pleased with the way it's going,'' said Dr. Mark A. Kane, a hepatitis expert at the Centers for Disease Control in Atlanta. ''We've gotten positive feedback from many people.''