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Hidden truth

Autopsy points out errors in the identification of the cause of death

NLMWork by Cajetano Bosa from 1803: examination in the open airNLM

Expensive modern exams are not always a synonym for a precise diagnosis. A study coordinated by oncologist Ana Lúcia Coradazzi, from the Amaral Carvalho Hospital in Jaú, in the interior of São Paulo, indicates that the correct identification of a disease still depends more on the skill of the doctor in investigating the patient’s complaints and carrying out a good physical examination than on new laboratory tests and equipment, like ultrasound and tomography, which produce images of the internal organs of the body.

The objective of the work, published in the Brazilian Journal of Medical and Biological Research and conceived by pathologist Mário Rubens Montenegro, from the São Paulo State University (Unesp), was to find out if the new methods of diagnosis could replace the examinations carried out by physicians. It seems not, and the results agree with an old suspicion of Montenegro, who was one of the first professors at Unesp’s College of Medicine in Botucatu. In his view, doctors attribute excessive importance to technology, and less value to the methods that are even today regarded as more accurate, such as clinical examination and an analysis of the patient’s history.

In partnership with cardiologist Antônio Luís da Costa Morganti, from the University of São Paulo, the researchers compared the medical records of 252 patients attended to at Unesp’s hospital with the information obtained in the post-mortem examination. 96 autopsies carried out between 1975 and 1982 were analyzed, and another 156 that were done between 1992 and 1996, after the inauguration of the hospital’s tomography sector.

The autopsy confirmed the diagnosis of the basic causes of death in 77% of the cases. It is the other 23% that called attention the diagnosis was wrong in almost half of them and the cause of death in the rest, which was not to be found in the medical bulletin, was only determined by means of the autopsy. For Ana Lúcia, these figures are similar to those for other hospitals in Brazil or in countries where more sophisticated examinations are common.

The level of right answers from the doctors diminished even more at the time of identifying the immediate cause of death, the acute problem that ended life. In 40% of these cases, usually attended to by doctors on roster duty, who had not accompanied the evolution of the disease, the result of the autopsy was different from the diagnosis made by the doctor. And in one of each four cases, the immediate cause of death was only determined in the autopsy and for this reason, it is regarded as essential for getting reliable data on the frequency of diseases and for controlling the quality of medical services.

Another fact that called attention: doctors often failed to register on the medical bulletin the secondary diseases, which did not cause death directly, but affected the patients’s health, like the obstruction of blood vessels or even cancer. “Specific, highly sensitive tests are needed, but they do not replace clinical practice for diagnosing a disease correctly”, concludes Ana Lúcia. “Without well-done clinical records and physical examinations, the doctor can be induced to ask for unnecessary examinations and to interpret them incorrectly, which makes diagnosis more expensive without making it more precise.”