Will virtopsy replace all autopsys?

[Dock1234]

Given how good imagining is and how good it might be in the future, do you think that autopsy will still be necessary in the future? Or will whole-body MRI be able to reveal everything that autopsy would?

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[pathstudent]

There is almost nothing to replace as the hospital based autopsy is almost extinct. My 400 bed community hospital we did 250 a year back in the 80s. Now we do 5. The place where I trained did 500 a year back in the 80s and 90s. In the early 00s they were lucky to hit 50 (and that even counted restricted autopsies. E.g. brain only, liver only, heart and lungs only. There was even a kidney biopsy only autopsy that we got credit for). Who knows what they do now.

I don't know if forensic autospy will be replaced. So many of those cases were diagnosed based on external pattern of injury.

 

[2121115]

Given how good imagining is and how good it might be in the future, do you think that autopsy will still be necessary in the future? Or will whole-body MRI be able to reveal everything that autopsy would?

We can only hope so.

 

[kchan99]

Given how good imagining is and how good it might be in the future, do you think that autopsy will still be necessary in the future? Or will whole-body MRI be able to reveal everything that autopsy would?

This is an interesting question... In my opinion, the decline in autopsy rates is partially related to the increasing use of clinical (in vivo) MRI. In the 1990s, there were fewer hospitals with MRI scanners than in the 2000s. However, this does not mean that MRI and other imaging should replace autopsy. For example, in brain MRI, images are as clear representations of the brain, but there is quite a bit of detail that is not visualizable or distorted. Furthermore, it would not be possible to determine etiology of disease using MRI in most instances. And there is quite a bit of imaging findings that have not been correlated with pathology. Therefore, MRI and other imaging modalities should not be considered the gold standard.

I recommend reading Magnetic Appeal by Kelly A. Joyce, a sociologist who studies the impact of medical technology on society.

May I ask -- are you thinking about a career in radiology? I've seen that you have posted about MRI and interventional neurology.

 

[mlw03]

Given how good imagining is and how good it might be in the future, do you think that autopsy will still be necessary in the future? Or will whole-body MRI be able to reveal everything that autopsy would?

I'm a forensic pathologist. This is a hot topic in our world. Short answer is 'hell no', as in, no, virtopsy will not replace forensic autopsies in my lifetime (and I'm in my 30s). Supplement perhaps, but replace, definitely not, for a lot of reasons.

 

[Dock1234]

I'm a forensic pathologist. This is a hot topic in our world. Short answer is 'hell no', as in, no, virtopsy will not replace forensic autopsies in my lifetime (and I'm in my 30s). Supplement perhaps, but replace, definitely not, for a lot of reasons.

Could you name some of those reasons as an example?

 

[dr4n6]

Dock 1234-very simply radiology can't retrieve bullet fragments, classify trauma, testify in court as to the nature of the timing of injuries or be of definitive assistance when the cause of death is made histologically, which is why radiology at best will only be an adjunct to the autopsy in forensic contexts.

 

[mlw03]

Dock 1234-very simply radiology can't retrieve bullet fragments, classify trauma, testify in court as to the nature of the timing of injuries or be of definitive assistance when the cause of death is made histologically, which is why radiology at best will only be an adjunct to the autopsy in forensic contexts.

I agree with all those reasons. The stuff I was thinking about has more to do with what CT is good at catching and what it isn't. CT is good for bony trauma, and in particular will diagnose (when read by a radiologist) non-displaced or minimally displaced fractures of the axial skeleton or the face. FPs rarely dissect the face in North America, and I am unlikely to diagnose a non-displaced fracture of a lateral process of a thoracic vertebral body. CT is good for that stuff. But it's not so good for soft tissue injuries, or as noted above, classifying those injuries.

Moving away from the world of trauma, one of my most common findings is severe coronary artery disease. Many times it is calcified, but often it is not. Would CT or MRI pick that up? What about an acute MI or a coronary thrombus (which is very tiny)?

So adjunct yep, replacement nope.

 

[Over9000]

Imaging is generally better for three things: bones, vascular anatomy, and brain.

Imaging has already supplanted autopsy in medical cases, which is appropriate. This is because the patient can be alive for the examination. And we wonder why medical autopsy has fallen out of favor...

Medicolegal cases will probably always require a gross examination at least for external findings, and I would wager probably for internal as well. I'm not a forensic pathologist but imaging could help find things that would be difficult to see after evisceration and could streamline the process that way.

 

[kchan99]

I agree with all those reasons. The stuff I was thinking about has more to do with what CT is good at catching and what it isn't. CT is good for bony trauma, and in particular will diagnose (when read by a radiologist) non-displaced or minimally displaced fractures of the axial skeleton or the face. FPs rarely dissect the face in North America, and I am unlikely to diagnose a non-displaced fracture of a lateral process of a thoracic vertebral body. CT is good for that stuff. But it's not so good for soft tissue injuries, or as noted above, classifying those injuries.

Moving away from the world of trauma, one of my most common findings is severe coronary artery disease. Many times it is calcified, but often it is not. Would CT or MRI pick that up? What about an acute MI or a coronary thrombus (which is very tiny)?

So adjunct yep, replacement nope.

I can't speak about CAD because I don't have any experience with cardiac MRI. In living patients, a CTA or MRA is routinely used to diagnosing intracranial and extracranial large and medium artery atherosclerosis (of course, not all forms of arteriosclerosis), but neither CTA or MRA would be useful in "virtopsy" because CTA requires an IV contrast bolus, and MRA is either time of flight (visualizes flow) or requires intravenous contrast.

 

[PinkIvy08]

My 2 cents is that it will augment, not replace...and this is still a long time off (at least in the US). Imaging is intended for the living, and as such hasn't progressed enough to detect subtle nuances that have profound effects on post-mortem diagnoses.

 

[LADoc00]

I havent done in post in years and years. Autopsies are as much a part of modern healthcare as leeches, tincture of cocaine and doctors giving women orgasms to prevent hysteria.

 

[mlw03]

I havent done in post in years and years. Autopsies are as much a part of modern healthcare as leeches, tincture of cocaine and doctors giving women orgasms to prevent hysteria.

Come on LA, you know that's hyperbole. Autopsies have value, not just in the forensic sense. Just this week I examined a woman with hemoperitoneum, and despite three days in hospital, the clinicians did not know why. She had imaging, and the radiologist could only say there was hemorrhage in the liver. Autopsy showed a hemorrhagic neoplasm. Nothing fancier than a scalpel to determine what first world modern medical technology couldn't solve.

 

[LADoc00]

1.) MLW I will ask you this, if indeed everyone thought autopsies added value, why has there literally never been a CPT code to reimburse them? Usually agencies assign codes to healthcare functions that add value.

2.) In addition, if regulators thought autopsies were central for the guarantee of quality, why were they eliminated from the requirements for in patient hospitals way back in the 1970s?

3.) Why are almost all new hospitals in the US built without morgues?

4.) Other than revealing a potential lawsuit for a patient's family, what positive effects do autopsies produce for the modern medical staff?

I cite your own example. Woman admitted with hemoperitoneum, radiology misses lesion, perhaps improper study was ordered. Autopsy reveals mistake. Who exactly is learning from this error?? Who attended the post with you? The radiologist? The admitting ED physician? Who even bothered to read the report?

Modern medicine is WAY to fast paced for something as incredibly anachronistic as the autopsy. Most reports are just fodder for attorneys nowadays.

Im not saying I like this, I actually hate it, but it is the state of things.

 

[mlw03]

I don't know what a CPT code is. The joy of being a pure FP.

I think it would be lovely if clinicians attended more autopsies, but that ain't gonna happen. You don't get paid to watch an autopsy. But this is about money, not quality of care or diagnostic knowledge.

You're talking about financial issues, not medical ones. It's hard to justify spending money on the dead, I get that. The decrease in autopsies has been driven by financial stuff primarily. I agree that not every dead person needs an autopsy, but to compare the autopsy to leeches is hyperbole. I think you and I fundamentally agree, but we're at different ends of the spectrum.

 

[randomlogik]

I am at a Children's hospital, and I feel autopsies in this setting do still hold some value. It is not uncommon to find a congenital anomaly or malformation of significance at the time of autopsy that was not previously known, and this information can be very helpful to a family. We have postmortem conferences where we meet with the family along with the clinician to review the autopsy findings. We are even going to be getting a remodel of our morgue shortly. None the less, our autopsy numbers have been decreasing for a variety of reasons. I don't think based on current technology that we will be replaced by imaging alone. Genetics and molecular studies will probably have a bigger role in at least pediatric autopsies in the future.

 

[LADoc00]

Okay, sheesh. Folks how do you know if autopsies provide ANY value to families whatsoever? I actually have sat down with families after doing a post long ago and universally the input they gave me was "Good, just wanted to make sure the doctors didn't screw up." When I surveyed if families would ever consider paying for an autopsy out of pocket given it was not reimbursed by anyone, 100% said they would not request an autopsy even it was just a token $200. 100%. Im sure there are rare random well off families or families of deceased patients who hated their doctors enough to pay for autopsies to see if they could sue, but I never surveyed a single one.

That's when I said enough is enough.

And yes I am talking about financial issues cause the dollars and cents is how society assigns value in the marketplace to goods and services. It's also what grown ups talk about when the kiddos finally to go sleep at night.

Just let this die already. I agree its a sad, lost tradition in a crumbling nation of dying traditions.

 

[mlw03]

Okay, sheesh. Folks how do you know if autopsies provide ANY value to families whatsoever? I actually have sat down with families after doing a post long ago and universally the input they gave me was "Good, just wanted to make sure the doctors didn't screw up." When I surveyed if families would ever consider paying for an autopsy out of pocket given it was not reimbursed by anyone, 100% said they would not request an autopsy even it was just a token $200. 100%. Im sure there are rare random well off families or families of deceased patients who hated their doctors enough to pay for autopsies to see if they could sue, but I never surveyed a single one.

That's when I said enough is enough.

And yes I am talking about financial issues cause the dollars and cents is how society assigns value in the marketplace to goods and services. It's also what grown ups talk about when the kiddos finally to go sleep at night.

Just let this die already. I agree its a sad, lost tradition in a crumbling nation of dying traditions.

You're talking your anecdotal experiences and extrapolating them to all autopsies. I've had plenty of forensic autopsies where families are glad to know what happened, whether it was excluding trauma or just knowing what medical disease caused the death.

I don't disagree that money is important. Damn important. But I won't say it's the only thing of value in this world or in the practice of medicine.

 

[BU Pathology]

I have spoken with a number of families about autopsy results and never have the families said that they regretted getting an autopsy. They have uniformly been appreciative of the explanations that were provided about the death of their loved ones.

I have also spoken with families who had a question about the death of a loved one where an autopsy was not performed, and answers could not be provided. These families uniformly wish they had agreed to an autopsy, or demanded an autopsy.

There are several CPT codes for autopsy 88000 for a gross exam only, 88027 with gross and microscopic including brain and spinal cord, in addition to three other codes.
https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/cpt4exc.pdf

 

[LADoc00]

A.) I am not at all questioning the value of post mortem examination to forensics. It is of paramount importance along with toxicology.

B.) I also not saying families wont tell you they feel thankful you can provide a post mortem report. What else are they gonna say? They just got 4-5 hours+ of free work out of a highly trained and absurdly over educated member of society. That will be likely be the first AND last time they get that pleasure in their entire lives.

When asked to pay something, IN MY EXPERIENCE, the answer has been an overwhelming 'No'. There is a big difference between a hamburger stand which can line up crowds when the burgers are free vs. one that can attract paying customers to keep itself going.

AND before someone posts that somehow BU Path has outsmarted the old LADOC, what he is referring to are GHOST CODES. They are nonsense codes which dont path to an actual payment within the CMS system. And then ask yourself why they exist to begin with and how much you really should trust your government.

Go here: https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

select 88000 as the code at the bottom and check all modifiers.

The current Physician Fee Schedule does not price the requested HCPCS Code(s).

 

[maxxor]

Moving away from the world of trauma, one of my most common findings is severe coronary artery disease. Many times it is calcified, but often it is not. Would CT or MRI pick that up? What about an acute MI or a coronary thrombus (which is very tiny)?

Radiology resident: yes, CT can very easily pick up calcified coronary arteries. We cannot pick up acute thrombus without contrast.

I can't speak about CAD because I don't have any experience with cardiac MRI. In living patients, a CTA or MRA is routinely used to diagnosing intracranial and extracranial large and medium artery atherosclerosis (of course, not all forms of arteriosclerosis), but neither CTA or MRA would be useful in "virtopsy" because CTA requires an IV contrast bolus, and MRA is either time of flight (visualizes flow) or requires intravenous contrast.

You can always see calcification without contrast, but you are correct, we cannot see if it is flow limiting or luminal narrowing without contrast or TOF.

 

[empresarose]

I'm a forensic pathologist. This is a hot topic in our world. Short answer is 'hell no', as in, no, virtopsy will not replace forensic autopsies in my lifetime (and I'm in my 30s). Supplement perhaps, but replace, definitely not, for a lot of reasons.

I agree!