This was interesting and actually very helpful! I've struggled with death certificates for 30 years! As you mention, no significant training in medical school (or residency) per my recollection. I had never found the linked CDC page and it is very helpful. l had no idea that "unspecified natural causes" was an option! This is a game changer, mainly for very elderly patients. As I review the lists on that page, I see many that would be easy to use and realize most of those would occur in a hospital and the inpatient person completes that death certificate. As you point out, outpatient medicine often makes determining cause of death more ambiguous.
I also appreciate the encouragement to question studies and "statistics" being presented. I have a questioning mind as well - if something presented does not follow anything I've observed in the world, I immediately question. (And I tend to be an optimist). Digging deeper helpful but not always easy. Unfortunately, I've found that during covid and persisting since then, if you question or challenge certain "studies" or "findings" or other claims, you can quickly be called a racist, a bigot, an "anti-vaxxer" a "climate denier". I have no idea the current state in medical school or residence is anymore - vigorous debate and questioning used to be welcome and a part of the scientific method. I'd imaging today might be very different.
There have been a number of studies showing that death certifications on cause of death are completely unreliable. The most common cause of death is probably old age and the failures of one or more organ systems that go with it. But "heart attack" and ASCVD are cited as the leading causes of death in the US. These default diagnoses are used by doctors to avoid the bureaucratic problems that ensue if one fails to provide an acceptable cause on the death certificate.
I cited a personal experience in a book I wrote about cholesterol and heart disease. One of my senior partners was called to a patient's home in order to pronounce him dead. The patient was lying in bed and was quite obviously dead. My partner slipped his stethoscope beneath the covers and listened for any sounds of respiration or heartbeat. Finding none, he affirmed the diagnosis and returned to the office to await the arrival of the death certificate from the funeral home for his signature. Since the patient was elderly and had a history of heart disease, he was prepared to certify it as a cardiac related death. It was an unpleasant surprise when the mortician called and asked Did you know that this man was shot in the chest?
A classic illustration of the inaccuracy of DC diagnoses. Also a pretty good illustration of the value of at least a cursory physical examination.
Your comment about being a pessimist (a trait we share) made me think of a sketch by the comedian Dara OBriain about statistics:
"I give out when people talk about crime going up, but the numbers are definitely down. And if you go, 'The numbers are down,' they go, 'Ahh, but the fear of crime is rising.'"
I applaud the effort of Dr. Datani in exposing how worthless our cause of death records are now. This is very personal for me! I was brought before theTexas Medical Board for charges of failure to complete the EDR(electronic death record) in the alloted time. I did the time, I paid the fine, I performed the prescribed CME(continuing medical education), and am still required to document my apparent failure as a physician. Was the patient harmed? Was there a hole left in the medical data critical to treating patients? The immediate personal effect, beside the aformentioned: I resorted to an underling perform the task, ON TIME. I think 99% reports after that were reported cardiac arrest. To this date, I cringe and immediately arrange an alternate reporter, for any EDR assigned to me. I am, only, pleased that I do not spend time and effort to analyze the myriad of medical issues that brought that patient to that end, however, I would not put any credance on the medical value of reported cause of death!
This could apply to any time series with unstable categories and human adjudication. Please unleash Saloni on DSM diagnoses for instance.
Saving Normal: An Insider's Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life; Allen Frances
Seems to me there are really three stories here. One is about death certificates, and it’s a cautionary tale and an interesting one that I haven’t often contemplated. The second is about churnalism. But my assumption, reading the headlines, was that the *rise* in maternal mortality had not, in fact, occurred. Instead, reading your piece and skimming Datani’s, I see that the *lower* rates for three decades starting around 1980 were the illusory ones, and the current numbers — reflecting the nationwide use of the pregnancy checkboxes on the death certificates — are more reliable. Now that is a very different narrative, with its own disturbing eclat. “Our rates are not rising after all” implies “nothing to see here, move along.” On the contrary! It sounds as if your tendency to pessimism is more warranted than ever, because the actual takeaway appears to be, “US maternal mortality has not in fact been as low as we thought for over 40 years now. To understand the current numbers, we should not be looking for recent changes in maternal circumstances or health-care policy, but rather re-thinking our entire approach for the past half-century.” Talk about a story.
This was interesting and actually very helpful! I've struggled with death certificates for 30 years! As you mention, no significant training in medical school (or residency) per my recollection. I had never found the linked CDC page and it is very helpful. l had no idea that "unspecified natural causes" was an option! This is a game changer, mainly for very elderly patients. As I review the lists on that page, I see many that would be easy to use and realize most of those would occur in a hospital and the inpatient person completes that death certificate. As you point out, outpatient medicine often makes determining cause of death more ambiguous.
I also appreciate the encouragement to question studies and "statistics" being presented. I have a questioning mind as well - if something presented does not follow anything I've observed in the world, I immediately question. (And I tend to be an optimist). Digging deeper helpful but not always easy. Unfortunately, I've found that during covid and persisting since then, if you question or challenge certain "studies" or "findings" or other claims, you can quickly be called a racist, a bigot, an "anti-vaxxer" a "climate denier". I have no idea the current state in medical school or residence is anymore - vigorous debate and questioning used to be welcome and a part of the scientific method. I'd imaging today might be very different.
There have been a number of studies showing that death certifications on cause of death are completely unreliable. The most common cause of death is probably old age and the failures of one or more organ systems that go with it. But "heart attack" and ASCVD are cited as the leading causes of death in the US. These default diagnoses are used by doctors to avoid the bureaucratic problems that ensue if one fails to provide an acceptable cause on the death certificate.
I cited a personal experience in a book I wrote about cholesterol and heart disease. One of my senior partners was called to a patient's home in order to pronounce him dead. The patient was lying in bed and was quite obviously dead. My partner slipped his stethoscope beneath the covers and listened for any sounds of respiration or heartbeat. Finding none, he affirmed the diagnosis and returned to the office to await the arrival of the death certificate from the funeral home for his signature. Since the patient was elderly and had a history of heart disease, he was prepared to certify it as a cardiac related death. It was an unpleasant surprise when the mortician called and asked Did you know that this man was shot in the chest?
A classic illustration of the inaccuracy of DC diagnoses. Also a pretty good illustration of the value of at least a cursory physical examination.
Your comment about being a pessimist (a trait we share) made me think of a sketch by the comedian Dara OBriain about statistics:
"I give out when people talk about crime going up, but the numbers are definitely down. And if you go, 'The numbers are down,' they go, 'Ahh, but the fear of crime is rising.'"
https://www.youtube.com/watch?v=zopCDSK69gs
I applaud the effort of Dr. Datani in exposing how worthless our cause of death records are now. This is very personal for me! I was brought before theTexas Medical Board for charges of failure to complete the EDR(electronic death record) in the alloted time. I did the time, I paid the fine, I performed the prescribed CME(continuing medical education), and am still required to document my apparent failure as a physician. Was the patient harmed? Was there a hole left in the medical data critical to treating patients? The immediate personal effect, beside the aformentioned: I resorted to an underling perform the task, ON TIME. I think 99% reports after that were reported cardiac arrest. To this date, I cringe and immediately arrange an alternate reporter, for any EDR assigned to me. I am, only, pleased that I do not spend time and effort to analyze the myriad of medical issues that brought that patient to that end, however, I would not put any credance on the medical value of reported cause of death!
This could apply to any time series with unstable categories and human adjudication. Please unleash Saloni on DSM diagnoses for instance.
Saving Normal: An Insider's Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life; Allen Frances
Never seen a link so coy - not the CDC one ;) Great read!
😂
Seems to me there are really three stories here. One is about death certificates, and it’s a cautionary tale and an interesting one that I haven’t often contemplated. The second is about churnalism. But my assumption, reading the headlines, was that the *rise* in maternal mortality had not, in fact, occurred. Instead, reading your piece and skimming Datani’s, I see that the *lower* rates for three decades starting around 1980 were the illusory ones, and the current numbers — reflecting the nationwide use of the pregnancy checkboxes on the death certificates — are more reliable. Now that is a very different narrative, with its own disturbing eclat. “Our rates are not rising after all” implies “nothing to see here, move along.” On the contrary! It sounds as if your tendency to pessimism is more warranted than ever, because the actual takeaway appears to be, “US maternal mortality has not in fact been as low as we thought for over 40 years now. To understand the current numbers, we should not be looking for recent changes in maternal circumstances or health-care policy, but rather re-thinking our entire approach for the past half-century.” Talk about a story.