Frigidarium of the Baths of Caracalla, Rome (built 212-216)
The history of medicine is starred with single-minded men and women who were not afraid to look into the cold bodies of those whom they had failed to save. They did their best, but saw the post-mortem as a final duty. Thus they learnt what went wrong, and moved on to the next patient with greater understanding . In the modern era, pioneers have had no hesitation in dissecting patients whom they have come to know well, in order to learn – the case of Philip Blaiberg comes to mind, the second person to receive a heart transplant performed by Christiaan Barnard (19 months after surgery, his coronary arteries showed widespread atherosclerosis, now recognised as a feature of chronic rejection). It seems unthinkable that such a patient would not have a PM.
There are two types of post mortem: those performed by coroners and those requested by hospital doctors. Coroners remain active (more so since Shipman) and regularly take on cases where there is uncertainty as to the cause of death, but their focus is forensic and not inquisitive. The results of their investigations are not routinely fed back to medical teams, and they do not have the time or the resources to approach corpses with broad-minded medical curiosity.
As doctors we can still arrange hospital PMs if we wish, but we rarely do (personal observation). Since the organ retention scandal at Alder Hey the consent process has become far more demanding, and the consent form [accessible via this site] for relatives is very detailed (if not downright harrowing). Bureaucracy and nervousness are possible explanations for the rarity of hospital PMs, but I wonder if there is more to it.
Speaking for myself, there is a stark contrast between the memory of a patient and the idea of their supine form giving up its secrets to the gloved hands of the pathologist. It is not mere squeamishness, but is, I believe, a more complex challenge. The cold plunge, from conversation one day to coarse incision the next, is shocking. Surely, the critic says, you are duty-bound to disregard such an emotional reaction, you must try to discover what happened. The 18th century, frock-coated and thick skinned physician in me thinks ‘Yes’… but the modern doctor, the one who reassured the patient on day 1 that they were looking at no more than a week in hospital, and who on day 3 began to talk about discharge dates, thinks ‘Wait… what good will it do him now?’ The sudden transfer from concern for the individual to the ‘greater good’ is too turbulent, too cold.
The emphasis in modern healthcare is, quite rightly, compassion, and this requires empathy – a form of connection. It encourages a move away from regarding the patient as a mere body, or a dynamic data set. There is emotional engagement. So when our patients die unexpectedly we experience shock, there is a compressed form of grief, there may be a hint of guilt…and while these muddy waters swirl across the scene, a question looms – ‘Shall we get a PM?’ Perhaps, sometimes, we need to regain some of that old fashioned, hard-headed hunger for answers, in order to catch the truth before it disappears forever. It is no easy task.