Patient Confidentiality and Post Mortum Examination, an unsolicited openion

Federal regulations unwittingly but systematically ended the modern era of medical education with current almost paranoid confidentiality rules and the abandonment through neglect of routine autopsy.

More than anything else, modern medicine evolved through bedside teaching and autopsy. The microscope helped. Dissection of cadavers despite the resistance of the church, the teaching of anatomy, post mortem examination and bedside teaching created the groundwork for scientific medicine.

Today confidentiality and patient choice more or less prohibit both autopsy and bedside teaching. Once, a covenant bound seriously ill patients willing to aid in the advancement of medicine, to a teaching program offering low cost treatment and advanced knowledge in accessible medical school hospitals and clinics.

Today, the medical school competes for the insurance dollar. Medical services cannot be discounted and the patient's medical conditions cannot be verbalized where others might hear. I encounter a bizarre situation wherein first year medical students can take a history directly from the patient but do not have access to the patient chart; they no longer use a microscope and some must make do with paid actors as patients.

I'm old enough to have learned medicine on a 20 bed ward when we did the admitting lab work and patient workup. Daily rounds were accompanied by the assigned professor, intern, resident and medical student. The student verbalized a brief summation of the patient's history followed by the intern, the resident and the professor -- expanding in depth on the pathology and the likely outcome. (Patients on the ward with similar conditions knew about and supported one another.)

Very little bedside teaching gets done today and not at all in non-medical school hospitals. --- We were, furthermore, required to attend 12 autopsies for the semester and write a summation of the findings with two journal articles relevant to those findings. A good life long habit to get into, that and looking yourself at your patient's gram stain or peripheral smear will find many mistakes before and after they happen.

While the didactic curriculum in today's medical school covers more ground in greater depth and at the molecular level, the absence of live patients suffering live pathologies leaves too much to the imagination. Lacking the visible, gross and microscopic findings from an autopsy, followed by a live conference arguing the facts, further detracts from the learning experience, and I might add the evolution of medicine. I think that these deficiencies may account for some of today's unfavorable outcomes.

Health care in the US produces dismal results at obscene costs by any public health metric. We were once indeed the envy of the world in medicine, but today, sadly, despite the glitter and the price, we turn out something like 37th in both longevity and perinatal mortality. By any reckoning we preform many unnecessary procedures and surgeries. 15% of diagnoses proves wrong. The first two providers statistically misdiagnosis or fail to diagnose cancer 45% of the time. We blithely claim that CAT scans eliminate the need for autopsy, and in the occasional post mortem actually preformed, we find as high as 60% unsuspected or misdiagnosed pathologies.

We might reinvent medical education with the mnemonic, "something old, something new, something borrowed and something blue," translated as old fashion bedside teaching, routine autopsies, genomics, a lesson from Europe and something blue. I would take the later to mean aggressive leadership from our medical schools rather than a profitable but unsustainable adaptation to the status quo.