Autopsy--the lost opportunity.

Mortui vivos docent, "the dead teach the living." The body of medical knowledge has expanded tremendously through painstaking autopsies performed by meticulous pathologists under the keen eye of clinicians eager to determine the cause of death and verify the accuracy of their diagnostic skills. Many clinicians have been humbled at one time or another to learn that their diagnosis was incorrect. Yet, it is an enriching experience to learn that a particular physical sign, or series of signs, could point to a different diagnosis than the one presumed. Attending autopsies was an integral part of undergraduate medical education and many clinicians routinely observed autopsies to confirm or refute their diagnosis. (1)

Over the past few years, however, the number of autopsies has steadily declined. (1,2) Fewer than half of the medical schools in the United States require attendance at autopsy, and most students graduate without attending a single autopsy. (3) The number of autopsies performed used to affect the accreditation of training programs. Now, as stated by Fergusson et al in this issue of the Journal, the current requirement of the Accreditation Council for Graduate Medical Education is that autopsies be performed whenever possible. (4) This is regrettable and akin to lowering a grading scale so that more may pass a test.

It is ironic that while we pride ourselves on practicing evidence-based medicine, critically evaluating medications through double-blind placebo-controlled trials, and demanding high specificity and sensitivity of the various tests we use, we accept without question the cause of death as stated on a death certificate. There is no doubt that the diagnostic tools we now possess greatly facilitate the diagnostic process and may therefore obviate the need for an autopsy to reach a diagnosis. (5-7) For instance, we no longer have to strain our ears to determine whether the second pulmonary sound is accentuated, and whether it is a third, fourth or a summation heart sound that we also are hearing. A number of highly sophisticated tests can determine whether or not the patient has sustained a pulmonary embolus. Despite the specificity and sensitivity of these tests, they are still not as good as the autopsy itself. So why are we reluctant to ask for them?

Is it because we are afraid to be proven wrong, especially in this litigious climate? The consequences of making a wrong diagnosis could be serious if the correct treatment strategy could have saved the patient's life. Yet, by becoming aware of our mistakes, we are less likely to repeat them. Is the fear of litigation or of having one's reputation tarnished such that we do not want to know the truth? I doubt it. Is it because clinicians cannot generate revenue by observing an autopsy and discussing the findings with pathologists? I hope not.

Is it because the image of the "doctor" is changing? Often physicians managing acute life-threatening conditions may be fully aware of their patient's cardio-pulmonary functions, but may be ignorant of what makes that patient an individual, distinct from other patients under their care. The tendency to focus on the acute medical problem is further exacerbated by the emergence of "hospitalists" who only provide care while the patient is in hospital and often have never seen the patient before the acute admission. Furthermore, the tendency to hospitalize only patients who are in dire need of hospitalization and to discharge them as soon as their condition is stabilized does not help clinicians know their patients. This in turn makes the request for an autopsy much more awkward for the physician, and much easier for the family to refuse.

Autopsies give us an opportunity to better understand a number of conditions and not only the immediate cause of death. For instance, we still do not fully understand the implications of Lewy bodies in the brain, amyloid and degenerative changes in various organs, and why some patients with only minimal osteo-arthritis are experiencing severe pain, while others with gross arthritic changes are not in much pain at all. Had Dr. Alzheimer not performed an autopsy on his patient, or if he had only performed a focused autopsy, he would not have had the opportunity to examine her brain. Had Sir James Paget not been intrigued by the appearances of his patients' bones, he probably would not have had the opportunity to examine them thoroughly during the postmortem examination.

For autopsies to achieve their full educational potential there must be a close collaboration between clinicians and pathologists. Sending the deceased for an autopsy and relying on the written report is not as good as meeting with the pathologist, sharing findings, formulating questions, and being present during the autopsy itself to ensure a fruitful dialogue. Although this is time consuming, it is probably time well spent.

We need to educate our medical students and physicians-in-training about the importance and educational value of autopsies. Autopsies stimulate deductive reasoning, facilitate the integration of diverse material, and may even enhance clinical problem solving in undergraduate and postgraduate education. (8,9) The best educational method is to set an example. We need to make an effort, ask for autopsies, and most importantly, we need to attend these procedures and engage the pathologists who perform them so that we can learn from our patients and sharpen our skills to better serve other patients. It would be unfortunate to miss this educational opportunity. Mortui vivos docent.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9704-0325

Please see "Consecutive Autopsies on an Internal Medicine Service" on page 335 of this issue.

References

1. O'Grady G. Death of the teaching autopsy. Br Med J 2003;327:802-804.

2. Lundberg GD. Medicine without autopsy. Arch Pathol Lab Med 1984;108:449-454.

3. Anderson RE, Hill RB. The current status of the autopsy in academic medical centers in the USA. Am J Clin Pathol 1989;92:S31-S37.

4. Fergusson RP, Burkhardt, L, Hennawi G, et al. Consecutive Autopsies on an Internal Medicine Service. South Med J 2004;97:335-337.

5. Charlton R. Autopsy and medical education: a review. J R Soc Med 1994;87:232-236.

6. Welsh TS, Kaplan J. The role of postmortem examination in medical education. Mayo Clin Proc 1998;73:802-805.

7. Chariot P, Witt K, Pautot V, et al. Declining autopsy rate in a French hospital: physicians' attitudes to the autopsy and use of autopsy material in research publications. Arch Pathol Lab Med 2000;124:739-745.

8. Galloway M. The role of the autopsy in medical education. Hosp Med 1999;60:756-758.

9. Sanchez H, Ursell P. Use of autopsy cases for integrating and applying the first two years of medical education. Acad Med 2001;76:530-531.

Ronald C, Hamdy, MD, FRCP, FACP 

Editor-in-Chief