An Old Doctor Reading Harrison’s Principles of Internal Medicine for the Last time

Chapter 6 Safety and Quality of Healthcare

More on safety.

There are many factors that have influenced improvement and safety in medicine but in my opinion the most important and effective were the routine autopsy and the predatory sleazy malpractice plaintive attorney. You must take the good with the bad from those lawyers but as distressing as they are they did serve a purpose.

And how I hate their television commercials. They peer into the camera with sad puppy dog eyes feeling your pain. “We don’t get paid unless we win.” They take 30% for their alleged pain and suffering and drive Bentleys.

Malpractice was not a big deal in 1973. Professional insurance rates were very low. Patients would never think of suing their physician. That changed by the early 1980’s. It was lawsuits gone wild. Notions of safety theory, systems theory and quality theory evolved.

My early initiation to medicine at the world-famous hospital made me realize that a good doctor working in a bad system will result in a bad or at best marginal outcome.

My transfer to complete my training at a university setting was my professional salvation and restored my faith in the integrity of the profession. At the university safety and quality assurance centered around doctors and the autopsy. (How much better it would have been were nurse’s included.)

At the university we had what was called “Death Breakfast.” I believe it met twice a month and in this meeting of residents and chief residents and the chairman of the department of medicine all deaths were discussed and reasons for the deaths identified.

The meeting took place in the Magnolia Room. We sat at a long oak table and a fantastic southern breakfast of country ham, grits, bacon, eggs, orange juice and lots of coffee was served.

If you didn’t have to present a death you ate ravenously, but if you had to present a death you ate cautiously. If you had to present a death and there was no autopsy you didn’t eat anything fearing it would come back up.

The chairman wanted to know why the death occurred and what could be learned from it. Discussions laser focused on issues that might have prevented a death. Lack of staffing or equipment was readily identified as was physician failure, infrastructure failure or nursing failure. Problems were identified at the ground level, not at a removed and poorly focused, often political, bureaucratic level complete with committees.

(A camel is a horse drawn by committee-I would have said giraffe)

Quality evolved from the “Death Breakfast.”

If you did not obtain an autopsy it was felt to be an insult to the deceased. You were questioned repeatedly until you admitted “I don’t know why the patient died.”

“You didn’t care to know why your patient died?”

“We did not get an autopsy.”

“What happened to the patient?”

“The patient went in for a cardiac catheterization.”

“Then what?”

“The patient had chest pain and went to the cath lab.”

“What was discovered?”

“Nothing, the coronary arteries were clean. On return the patient became anxious, couldn’t breathe, and had a cardiac arrest from which she could not be resuscitated.”

“Was it a pulmonary embolus?”

“I don’t know.”


“I don’t know.”

“Ruptured gastric ulcer?”

“I don’t know.”

“Was there a complication of the cardiac cath?”

“I think most likely.”

“What most likely do you think happened?”

“I think the arteries were injured during the cath. A dissection.”

“But you don’t know?”


“Would an autopsy of helped?”


“But without an autopsy we will never know. Nothing can be learned from this woman’s tragic death. Your patient died like a dog in the street.”

Tough love. It has been forty years but the lesson is well remembered.

A return to the autopsy could help us as a profession. It may have kept the plaintive attorneys at bay. It would have improved the learning process at the individual level and therefore at a systems level. Problems would be delt with immediately and preventively and all would be aware.

The autopsy has pretty much become a relic and no longer the center of education or quality assurance.


The chapter reveals that several agencies came into being as the autopsy grayed and the attorneys thrived. Organizations such as the National Quality Forum and the Joint Commission are the guarantors and protectors of patient care and quality improvement. They evaluate quality at a distance and use computer generated algorithms and guided tours of hospitals. But they are removed from the bedside.

These noncombatants took up pain as “the fifth vital sign” in the early 2000’s which encouraged the widespread use of opiates and I believe to be partly responsible for the opioid epidemic plaguing us today. Drug overdoses are believed to be the major reason why our life expectancy has declined.

Prior to this suspect campaign we were very circumspect in prescribing pain meds. We had to learn it all over again. Now we are overly cautious and rely on pain clinics.

With Covid and the opioid crisis I am concerned life expectancy will fall further.

Chapter 6 sites a study from the RAND Corporation stating, “the chances of getting high quality care in the United States was little better than a coin flip.”

Coming soon Chapter 7

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