The dead shall teach the living

Endocrine Today interviews pathology expert about the current use of autopsies.

Despite all the medical advances made since the beginning of modern medicine, there is one basic question that every physician must eventually ask: Why did this patient die?

The autopsy and the physicians working in pathology often help to answer that question.

Alan L. Schiller, MD, the chair of the Lillian and Henry M. Stratton-Hans Popper Department of Pathology at Mount Sinai School of Medicine, recently spoke with Endocrine Today about the role of the autopsy in modern medicine. (Read the March 10 History of Medicine column on autopsy.)

Alan L. Schiller

Why should physicians take an interest in this topic and consider requesting autopsies of more patients?

The autopsy is the only final check on what physicians do to patients before they die. The autopsy report in the patient’s chart is the final chapter written on that patient in which physicians can correlate everything that was done during life and treatment with what they see upon death.

Humans make mistakes. Autopsies help us to see that there may have been errors made in treatment and it will stop us from making the same errors again in the future. Physicians may discover things in the autopsy report that will make them say, ‘Maybe we shouldn’t have given the patient this drug or this dose.’

Why is the autopsy still a useful tool in modern medicine?

The simple answer is physicians don’t always know why patients die. That’s the most myopic, the most narrow-minded way of looking at it. We should do an autopsy to find out why patients die.

Secondly, despite all of our new and emerging technologies, we don’t always know how accurate the technologies are. The autopsy can evaluate the veracity of all the new technologies, of imaging studies, the effects of drug treatment and even surgical procedures. Physicians would be able to evaluate how effective all of the above are on specific diseases.

For example, if a physician is trying a new therapy for a certain cancer, an autopsy would be able to evaluate the extent of the cancer. It could correlate the growth of the cancer with what was seen in imaging studies. It could tell a physician how much necrosis was knocked out with the therapies. We could evaluate all of that at the autopsy table. Physicians could see any detrimental effects of the treatment that may have nothing to do with the cancer.

In addition to the above, there are a whole host of epidemiologic questions that play a role in the importance of autopsy. Physicians can learn more about genetic diseases, what effect there are on the body, and how they are acquired. Autopsies have found infectious diseases that we never suspected might be there. It has discovered new diseases, such as AIDS, legionnaire’s disease and septic shock syndrome. All these things were picked up at the autopsy table.

Furthermore, we are in the age of terrorism now. We always want to evaluate peculiar deaths to make sure that there was no external environment, such as poisons, gases or toxins, which had an effect.

Autopsies are helping us begin to understand what happened to people during the World Trade Center attacks. We are starting to see material and autopsies on patients who probably had disease contracted from Sept. 11, 2001. We are beginning to understand what happened to these patients.

Autopsy rates have fallen from about 50% of hospital deaths in the 1950s and 1960s to less than 5% today. Why have those numbers continued to fall?

Around that time, it was compulsory for hospitals to autopsy 20% of people who died. The Joint Commission abolished that around 1971 or 1972. That didn’t help the number of autopsies grow.

One of the biggest causes for the decline in numbers is fear of legal suits. Doctors are afraid to have autopsies on patients because they think it’s going to uncover something that they did that should never have been done and open them up to a lawsuit. This is ironic because most of the time the autopsy will absolve the doctor rather than point the finger.

In addition, many times by the time a doctor gets an autopsy report, it may be weeks after the patient died and they have forgotten the details of the case or don’t have enough time to read the report.

Also, with medicine starting to emphasize subspecialization, when someone dies, who is called? Who is the caring doctor? You call a subspecialist who may have just seen a patient once, but he was the last person to see him. Who was really taking charge of the patient from beginning to end? Who does the report go to? Who has evaluated and taken over the entire care of the patient?

That, combined with the fact that most medical students have never seen an autopsy, makes things even worse. Today’s medical students are not familiar with it and they don’t understand what it really is.

When autopsies became popular they were a vital part of any student’s medical education. Are there any schools that still use the autopsy as part of their basic medical education?

At Mount Sinai we still try to place an emphasis on the autopsy. We give lectures on autopsy. We invite students to come and see an autopsy. I think that is pretty proactive but most medical schools don’t do that.

Performing an autopsy used to be mandatory for students. When I was in medical school, every student had to write up an autopsy, but that is gone. I don’t know of any medical school that really makes autopsies mandatory and uses it as a central core of learning.

Is the expense of doing an autopsy a problem?

For the family the autopsy is free. If you were a patient at a hospital, almost any hospital will carry out an autopsy free of charge. You are entitled to a free autopsy. The hospital covers the cost. There is no insurance that covers that. There is no policy or Medicare payment to the hospital that covers the cost of an autopsy. It is grouped under Medicare payments for resident education. That means that an autopsy is a money losing thing for everyone except the patient.

Pathologists, ironically, are also not pushing for an increase in autopsy rates either, because they don’t get paid extra for it. A careful autopsy takes two to three hours, and that is just to do the dissections. Then you have to do all the microscope work, correlate that and write it up. It requires a great effort.

In the end, despite the general acceptance by the medical community that an autopsy does have some clinical value, it is generally not a priority. No one makes any money on an autopsy. – Interview by Leah Lawrence