Cause of Death: 50% of Medical Residents Fib

Diedtra Henderson

May 10, 2013

Some 48.6% to 58.4% of residents from more than half of the residency programs in New York City have knowingly entered the incorrect cause of death on death certificates — errors that have implications for epidemiology, public health research, and disease surveillance — according to result from a recent study.

Barbara A. Wexelman, MD, MBA, from St. Luke's–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York City, and coauthors report their findings in an article published in the May 9 issue of Preventing Chronic Disease, published by the Centers for Disease Control and Prevention.

As fewer autopsies are performed, Dr. Wexelman and coauthors note, death certificates have become even more important sources of information about how Americans die. Public health researchers rely on death certificates to gauge the leading causes of death and to identify disease outbreaks, and the certificates also influence funding policies and research priorities.

In most teaching hospitals, it falls to resident physicians to complete the forms. To examine their experiences and opinions, the researchers conducted an anonymous, Internet-based, 32-question survey of New York City's 70 internal medicine, emergency medicine, and general surgery residency programs in May and June 2010. Some 521 residents from 38 residency programs responded to the survey; 178 of the residents were termed "high-volume" respondents, meaning they had completed 11 or more death certificates in the previous 3 years.

Forced to Do It

"Almost half of all respondents (48.6%) and 58.4% of high-volume respondents reported they had identified a cause of death on a death certificate that did not represent the true cause of death. More than half of the residents (54.0%) reported they were unable to list what they felt to be the correct cause of death after guidance from the admitting department in their hospital," Dr. Wexelman and colleagues write.

"Of all respondents, 70% believed they were forced to identify an alternate cause of death when the patient died of septic shock (compared with 83.5% of high-volume respondents), and 34.2% believed they were forced to identify an alternate cause when the patient died of acute respiratory distress syndrome (compared with 44.3% of high-volume respondents)," the researchers continue.

Only 20.8% of respondents knew they could hedge the death determination by calling it "probable," "presumed," or "undetermined." When the death certificate system would not accept the true cause of death or hospital admitting staff overruled them, 64.6% of respondents reported cardiovascular disease, 19.5% pneumonia, and 12.4% cancer as the cause of death.

Study participation was voluntary, and residents with stronger feelings about the accuracy of death certificates may have been more interested in participating. Other study limitations include the potential for recall bias.

"Residents routinely reported diagnoses on death certificates that did not match their medical judgments. These errors may have lasting effects on the public health priorities of the community. Reform is needed both in the training and education of residents and in the system itself," the authors conclude.

Support for this study was provided by Columbia University College of Physicians and Surgeons. The authors have disclosed no relevant financial relationships.

Prev Chronic Dis. 2013;10:120288. Full text

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