“Buried Answers”

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The Story

“Buried Answers”
http://www.nytimes.com/2005/04/24/magazine/24AUTOPSY.html
by David Dobbs
The New York Times Magazine, April 24, 2005

The Pitch

[Dobbs notes: This was my first sale at the Times Magazine. I sent the email “over-the-transom” to Gerry Marzorati, who had just been promoted to EIC at the Times Magazine. He had sent warm rejections to a couple prior story pitches and asked for more.

The Story I wrote closely resembled the story pitched, though the structure was quite different; I put the actual autopsy at about 2/3 of the way into the piece rather than at the opening.

The pitch was passed to a senior editor who phoned 3 weeks after I sent it and assigned it over the phone. Two months later I turned the story in and it ran 3 weeks after that, faster than usual because another story due to run had apparently been delayed or fallen apart.

That was my first story at the Times Magazine, and pretty much changed everything.]

January 6, 2005 [by email]

Dear Mr. Marzorati,

We talked a few years ago after I sent you a query about the row created in environmental circles by William Cronon’s assault on the concept of wilderness; you passed on the story but asked me to let you know when I had something else that seemed suitable for the magazine. (Congratulations on being chosen to take Adam’s place, by the way.) I’ve been following several subjects lately that might be of interest, from the growing prescription-drug scandals to flaps over the role of fMRIs in cognitive neuroscience, but at the moment I’d like to see if you can use a story on the “The Autopsy : How Its Premature Death Could Lead to Yours.” This story would examine how the steady decline in use of the autopsy threatens our individual and public health.

The autopsy — the most powerful tool in the history of medicine, responsible for most of our knowledge of anatomy and disease, and still a vital tool of diagnosis and public health — has become a dying art. Autopsy rates in the U.S. have fallen from 50% in 1950 to about 10% today
and continue to drop. The reasons include doctors’ fear of lawsuits, more distant relations between physicians and patient families (generating fewer requests and fewer consents for autopsy), the cost (about $4000, not covered by insurance), and a sort of technological hubris. Convinced that MRIs, CAT scans, and other imaging technologies reveal the body as well as dissection does, many doctors feel that by the time a patient dies, they’ve seen all there is to see. Yet autopsy analyses repeatedly show that the rate of major diagnostic errors — that is, errors contributing to a patient’s death — holds at around 30 percent, which is roughly what the first such studies found in 1920. We keep missing things — only now, with so few autopsies done, we’re less likely to know it.

Of course, even if doctors never blew a diagnosis or mishandled a treatment, their patients eventually die of something untreatable. Autopsies can’t change that. But autopsies contribute uniquely to medicine’s real goal, which is to recognize and address every treatable ailment. The post-mortem remains the only way to show doctors when they’ve failed that mission. It also remains essential for detecting and researching health threats ranging from Sudden Infant Death Syndrome and Alzheimer’s to infectious diseases such as HIV, West Nile virus, SARs, hantavirus, and prion disorders such as the human form of of mad cow disease. Yet the forces discouraging autopsy are relegating it to special cases and teaching hospitals. As many public- health and pathology experts have noted, this stands to compromise public health by obscuring both mistakes and possible new pathogens and diseases.

The story would likely open with an account of a pathologist (perhaps Gayle Winters, head of Harvard’s Medical School’s Department of Pathology, which does autopsies almost daily) as she conducts a post-mortem and describes both what she is finding on the table before her and what autopsy offers both the individual case and the broader cause of medicine. It would then briefly describe the autopsy’s history (including its transformation from a tool of anatomical exploration in the Renaissance to one of education and then diagnosis and epidemiology) and describing some of the crucial autopsy discoveries and contributions of the 20th century.
Finally, the story would examine the roots and implications of the decline the autopsy has seen since the 1950s, the specific sorts of treatment mistakes and public-health threats it helps detect (and may miss if the present declien continues), and the prospects for reviving its role in both quality control and public health. I would draw a growing body of writings on the subject as well as from interviews with current advocates and practitioners such as Harvard’s Gayle White and pathologists Frank Gonzalez-Crussi of Chicago and George Lundberg, former editor of the Journal of the American Medical Association and present editor of Medscape.com. The story would leave the reader with both a sense of the autopsy’s history and, more immediately, of what medicine stands to lose if its decline continues — a crucial check at a time when so many forces seem to threaten the quality and credibility of our medicine.

I am the author of Reef Madness: Charles Darwin, Alexander Agassiz, and the Meaning of Coral, to be published by Pantheon in January (more below), as well as two earlier books on science and the environment, The Northern Forestand The Great Gulf. My articles and essays have appeared in magazines ranging from Audubon to Scientific American Mind; my most recent two stories for Scientific American — a pdf galley of on the pediatric SSRI crisis and a MS on a controvery over fMRIs — are attached.

Let me know what you think, and please call or write with any questions.
Yours,

David Dobbs Montpelier, Vt.

http://daviddobbs.net

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