ABP autopsy requirement

[Sulfinator]

I have recently heard rumors (from folks involved in the PRODS Council and NAME) that there is real talk now of reducing or eliminating the ABP requirement for 50 autopsies in order to be AP board eligible. In my personal opinion, I think it's not a bad idea to at least reduce the number of autopsies, though I'm not sure about eliminating them altogether.

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[Substance]

Why not? Autopsies are by and large useless outside of forensics.

 

[LADuck00]

Seems like a dead topic.

 

[mlw03]

If this happens, the only people left in society who will be qualified to perform an autopsy will be forensic pathologists, and we're quite busy handling the cases we legally have to. Being honest, without a tech's help, how many people on here could actually do their own autopsy, start to finish? Even with the requirement, most AP pathologists can't do an autopsy. I'm not saying this is a bad thing. But are we far from the day when PAs "do" the autopsy (gross dissection, including organ examination), a pathologist interprets the micros, and then they work together to produce the autopsy report?

 

[member0007]

I think just do away with the requirement all together would be my vote. If they want to contact, I am happy to go on at length about that and explain why they should not be requirement and 50 is too high a number, just doing like 20 is enough. I would sent them all to a ME if that were possible. I think almost every 4th case should technically be referred to the ME from the hospital and should be done there, especially when the family member and other doctors are like, to loosely quote all of them at the same time - que? quoi? what happened? he/she was fine, how did this occur? we need autopsy now!!! - yikes.

 

[2121115]

If this happens, the only people left in society who will be qualified to perform an autopsy will be forensic pathologists, and we're quite busy handling the cases we legally have to. Being honest, without a tech's help, how many people on here could actually do their own autopsy, start to finish? Even with the requirement, most AP pathologists can't do an autopsy. I'm not saying this is a bad thing. But are we far from the day when PAs "do" the autopsy (gross dissection, including organ examination), a pathologist interprets the micros, and then they work together to produce the autopsy report?

But is that such a bad thing? Hospital autopsies are few and far between. I'm sure they can get worked in somewhere. PA's should be doing autopsies, IMO of course.

 

[pathbot]

We definitely need to reduce the numbers required, perhaps to 20 or so. As they are becoming less common it is harder and harder for residents to get numbers, resulting in more time and effort spent throughout residency on autopsy and less time to spend on surg path, cytology, etc. I feel that our specialty has long been plagued with spreading training too thin--the typical AP/CP resident will have rotated in many diverse areas but usually comes out of residency ill-equipped to practice general pathology.

What would benefit us the most is to reshape residency so that 3 solid years are spent focusing on surg path, cyto, and hemepath--skills most necessary for most jubs and general practice. Perhaps a year on CP (blood bank, micro, chem) at most is adequate to get introduced to it, and those interested can acquire additional training through fellowships, etc. Just my thoughts on how training could best prepare pathologists for their real job. But definitely feel that autopsy requirements have become much more of a hindrance to training than beneficial.

 

[2121115]

Some residency programs require 6 months of hospital autopsy and 2-3 months of cytology. Madness.

 

[Substance]

Some residency programs require 6 months of hospital autopsy and 2-3 months of cytology. Madness.

Your field seems to have a very big disconnect between training in practical skills and sticking to rituals. The requirement for autopsy is one of those rituals.

The above curriculum which 2121115 lists is akin to general surgery doing six months of emergency medicine and three months of colorectal surgery.

Yours is not the only field where the academics and community docs are at odds, but the degree to which the worldviews differ between those groups is the greatest in pathology.

 

[turtle1966]

Some residency programs require 6 months of hospital autopsy and 2-3 months of cytology. Madness.

One time (circa 1980-90), a chairman was making waves by proposing a wider adoption of autopsy as the future of pathology.

The autopsies in hospital setting are fraught with problems:

1-it is time consuming and unpleasant (to most);
2-damaging autopsy finding(s) may hurt medical staff, hospital and you; so you (may) become a passive accomplice (by omission) in a cover up.
3-It is Part A funded, which tends to be small to nothing depending on your contract.​

Therefore, why should not autopsies become domain of a sub-specialty, i.e., FP? Just ban free hospital autopsies.

 

[Cellpathology]

Autopsies are terrible.......too much scut work involved......too much time, energy, and effort....... Hard to justify not training the residents to some extent....... I do not see why 50 is a required number........95% of any "required number" of anything is always arbitrary and generally obstructive to real learning.........definitely pathology residency needs to think LONG AND HARD about restructuring the training.......CP should go its own way........quite honestly clinical teams like heme onc would be better to run the blood banks and apheresis units... they just are not interested....... all the other stuff is boring stuff that PhDs are more than capable of handling...... (i don't consider heme CP)

 

[Glass Pusher]

Some residency programs require 6 months of hospital autopsy and 2-3 months of cytology. Madness.

I can definitely vouch for this as my program fits this bill (though it may be 5 hospital/1 forensics). Completely ludicrous. One of the most glaring examples of where pathology training is completely out of touch with reality.

I suppose the fact that programs only have to worry about training residents for fellowships, they don't and will continue to not care. No need to worry about residents actually being competent practitioners in the community like every other field in medicine.

 

[2121115]

Your field seems to have a very big disconnect between training [and] practical skills...

Truer words were never spoken. Hence, the multiple fellowships and some areas virtually requiring a surgpath fellowship for job consideration.

 

[Cellpathology]

I can definitely vouch for this as my program fits this bill (though it may be 5 hospital/1 forensics). Completely ludicrous. One of the most glaring examples of where pathology training is completely out of touch with reality.

I suppose the fact that programs only have to worry about training residents for fellowships, they don't and will continue to not care. No need to worry about residents actually being competent practitioners in the community like every other field in medicine.

But you know, just to be clear, all residency programs are getting worse, some more than others.......medical schools as well.........Who is more useless than a new medical graduate?

 

[pathstudent]

The hospital I work at did 300 autopsies a year in the 70s and 80s. The pathologists did them unassisted and the work was not reimbursed.

Now we do about 5 a year. Have a local deiner guy come do the dissection and the hospital pays us a grand.

Get rid of the requirement. It is an anachronism.

 

[mlw03]

But is that such a bad thing? Hospital autopsies are few and far between. I'm sure they can get worked in somewhere. PA's should be doing autopsies, IMO of course.

Nope, not necessarily a bad thing. Heck, many FPs would be glad to do them for 2K each, and would be glad for a little extra cash. But many offices discourage or disallow outside work by the forensic pathologists.

 

[turtle1966]

Nope, not necessarily a bad thing. Heck, many FPs would be glad to do them for 2K each, and would be glad for a little extra cash. But many offices discourage or disallow outside work by the forensic pathologists.

Private, independent practice of FP. In my area they appear to be prospering.

 

[BlondeDocteur]

I have no dog in this fight (yet) but isn't private autopsy a thing? Where families request a second opinion on a prior autopsy, or where small hospitals contract them out? I thought they paid well.

 

[mlw03]

Different business models for FP exist - private groups or solo contracting is one of them.

To BD - one point to remember is there is no right to an autopsy. A family may want one, or a second opinion, but they have to find someone willing to do it for a negotiated amount of money. In some cities, there may not be any group or individual pathologist interested in doing that work, or they may charge more than a family is willing/able to pay. Forensic autopsies are governed by very specific laws in each jurisdiction, but private autopsies are a different ballgame. For the amount of money generated, many non-FPs have no interest in doing them, and like I said, finding an FP to do it is hit and miss. Even if I legally could at the moment (and I don't know if I can... work permit issues), I wouldn't do it for any amount of money. Many of my colleagues in FP feel the same - that in our free time, we're just not interested in doing this.

 

[turtle1966]

To BD - one point to remember is there is no right to an autopsy.

This used to be required by "standard" hospital contracts.

 

[mlw03]

This used to be required by "standard" hospital contracts.

Sorry, I should have been more specific. I meant out in the community. I don't know what hospital contracts state, and didn't mean to imply anything either way in that regard.

 

[turtle1966]

Sorry, I should have been more specific. I meant out in the community. I don't know what hospital contracts state, and didn't mean to imply anything either way in that regard.

I think you gave us a very valuable info, i.e., family has no "right" to an autopsy; we often thought that they had, this from our residency training days.

 

[deleted314957]

I think you gave us a very valuable info, i.e., family has no "right" to an autopsy; we often thought that they had, this from our residency training days.

In my 20+ years as a medical director in a community hospital I never did family requested posts.

 

[pathstudent]

In my 20+ years as a medical director in a community hospital I never did family requested posts.

We have the same policy. We defer on family initiated requests and refer them to the coroner who will do them for about 3000.

 

[turtle1966]

We have the same policy. We defer on family initiated requests and refer them to the coroner who will do them for about 3000.

A sound and smart policy!

 

[deleted314957]

CAP has published lists ( by geographic location) of pathologists who will perform "private" autopsies for a fee. As with mlw03, during my brief time ( 2 years) as an M.E.
we were not allowed to do private autopsies nor would we/I have had any interest. There are some scattered companies that have recruited willing pathologists such as 1-800-autopsy (now defunct?)
Most of these CAP-list folks are either semi-retired/un-employed/under-employed. I have seen a few fired/disgraced former M.E.'s on such rosters. They often function as paid "experts"/hired guns
to support themselves and seem pretty desperate for money. Once had a classic and tragic presentation in my hospital career of a young post partum woman with sudden death that screamed massive PE.
I opened her chest and she had a text book saddle embolus. The private (unemployed- fired FP/ME) pathologist who was paid to do a "second"autopsy ( lawyer and family requested) came up with the most asinine conclusions you can imagine. Monetary desperation on the part of the lawyer/ family/pathologist is an amazing thing!

 

[BlondeDocteur]

What is the reason why they are performed so infrequently in the community? Liability/exposure, or remuneration? It might seem naive, as the patient is obviously deceased, but are they ever covered by insurance (if performed before hospital 'discharge'- body transport?)

If they aren't reimbursable, do academic hospitals just eat the costs? I know there are these hybrid research/autopsy jobs out there (where someone is 90%+ research and their lone clinical teaching contribution is to run the hospital autopsy service). Is this just a training benefit or does it somehow generate revenue for the department?

 

[pathstudent]

What is the reason why they are performed so infrequently in the community? Liability/exposure, or remuneration? It might seem naive, as the patient is obviously deceased, but are they ever covered by insurance (if performed before hospital 'discharge'- body transport?)

If they aren't reimbursable, do academic hospitals just eat the costs? I know there are these hybrid research/autopsy jobs out there (where someone is 90%+ research and their lone clinical teaching contribution is to run the hospital autopsy service). Is this just a training benefit or does it somehow generate revenue for the department?

They have decreased everywhere. The decrease has been more dramatic in most community hospitals I imagine. Like I said at my hospital they have gone down from 300 to about 5 a year over the last 25 years. At my residency program they had decreased from 500 to about 80 over the last 20 years. We had to do about 4 months of autopsy to hit about 25 and then had to finish the rest at the coroner office in our 1 month forensic rotation. Total waste of training if you ask me. The only good thing is that it was kind of a chill month when autopsy.

 

[mlw03]

What is the reason why they are performed so infrequently in the community? Liability/exposure, or remuneration? It might seem naive, as the patient is obviously deceased, but are they ever covered by insurance (if performed before hospital 'discharge'- body transport?)

If they aren't reimbursable, do academic hospitals just eat the costs? I know there are these hybrid research/autopsy jobs out there (where someone is 90%+ research and their lone clinical teaching contribution is to run the hospital autopsy service). Is this just a training benefit or does it somehow generate revenue for the department?

Now you're getting towards the heart of this matter - $$$. I don't know the details the business models out there for how non-forensic autopsies are paid for (in ME or Coroner systems, funding is via the government [state, city, province, regional, etc]). Suffice to say, it ain't profitable. Those hybrid positions out there you speak of - those people better generate a lot of research money to stay employed. I knew one guy like this in residency, and he was scary as a diagnostic pathologist (but supposedly a solid research guy).

So in the end we have fewer autopsies getting done outside the forensic setting, and fewer people qualified to do them. So I get why the ABP is considering dropping the requirement. Families will be the ones to suffer, when they can't find someone within 1000 km to do an autopsy on their family member. The demand just isn't there often enough though for economic viability.

 

[pathstudent]

Totally disagree that money is a significant factor. The docs and families that would request them don't care about expense. The requests for autopsies have plummeted and it is not because pathologists don't want to do them (which in general we don't) or because hospitals don't want to pay for them. There has been a cultural shift driven in part by the fact hat we know so much more about what is going on before death with imaging and more extensive lab tests and procedures. Probably many of the autopsies in the past were unnecessary in the past and just done because of the autopsy culture at the time.

 

[Virchows_Archive]

Long time lurker but felt the need to surface in order to comment here:

Data exists that autopsies are not particularly detrimental to defense of malpractice suits at therefore should not be avoided to "protect other clinicial services":

Bove KE, Iery C; Autopsy Committee, College of American Pathologists. The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions. Arch Pathol Lab Med. 2002 Sep;126(9):1023-31. Review. PubMed PMID: 12204050.​

Data exists that the rate at which autopsies detect missed diagnoses/misunderstood findings has not changed over several decades despite the increase in imaging modalities and studies:

1. Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F. Diagnostic errors in three medical eras: a necropsy study. Lancet. 2000; 355(9220):2027-31.
2. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21):2849-56.
3. Pastores SM, Dulu A, Voigt L, Raoof N, Alicea M, Halpern NA. Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients. Crit Care. 2007; 11(2):R48
4. Wittschieber D, Klauschen F, Kimmritz AC, von Winterfeld M, Kamphues C, Scholman HJ, Erbersdobler A, Pfeiffer H, Denkert C, Dietel M, Weichert W, Budczies J, Stenzinger A. Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in East and West Berlin. PLoS One. 2012; 7(5):e37460.

Autopsies aren't billable but are covered by various payments to the institutions (hospitals) because they play a role in QA and QI activities. Our failure to educate other physicians about the importance of autopsy in understanding disease, understanding course for individual patients and understanding poor outcomes lies at the heart of much of the discussion which has already occurred here. With the increasing frequency of patients to have been involved in clincial trials (oncologic, cardiovascular, etc), the need to assess the distribution and character of pathologic processes post-treatment has taken on an increasing role. This is not a role for which forensic pathologists are trained. In fact, this type of activity should be a critical position for the pathologist in the health care delivery system, rather than simply anonymously rendering diagnoses as a simple interface between a glass slide and an electronic document. When seen as a critical player in understanding health outcomes, the pathologist becomes an increasing important member of the community -- this will be the key to gaining an appropriate share of resources when reduced reimbursements are being distributed within Accountable Care Organizations.

 

[Autopsy101]

What is the reason why they are performed so infrequently in the community?

In my experience, there are many reasons. The main reasons brought up at our hospital quality committee meetings are that JCAHO has removed the autopsy number requirements for hospitals for quality control. Other reasons discussed include clinicians and nurses are either uncomfortable asking for an autopsy, unfamiliar with the process of obtaining an autopsy, concerned about medical/legal implications of discovering a missed diagnosis, and most deaths in the hospital have a known or suspected diagnosis.

Liability/exposure, or remuneration? It might seem naive, as the patient is obviously deceased, but are they ever covered by insurance (if performed before hospital 'discharge'- body transport?)

As far as I know, autopsies are never reimbursed by insurance.

If they aren't reimbursable, do academic hospitals just eat the costs? I know there are these hybrid research/autopsy jobs out there (where someone is 90%+ research and their lone clinical teaching contribution is to run the hospital autopsy service). Is this just a training benefit or does it somehow generate revenue for the department?

Most hospitals cover costs of their own, in-house patient deaths without charge to the family, ie eat the cost. Some residency programs in our state offer fee-for-service autopsies for patients who die outside the hospital and do not meet the criteria for a forensic exam. They have an upfront fee schedule that they charge the family before performing the autopsy based on whether the exam is complete or limited/restricted. We don't do that in our program, but I would imagine that this set up would bring in some revenue to the department.

 

[Substance]

Long time lurker but felt the need to surface in order to comment here:

Data exists that autopsies are not particularly detrimental to defense of malpractice suits at therefore should not be avoided to "protect other clinicial services":

Bove KE, Iery C; Autopsy Committee, College of American Pathologists. The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions. Arch Pathol Lab Med. 2002 Sep;126(9):1023-31. Review. PubMed PMID: 12204050.​

Data exists that the rate at which autopsies detect missed diagnoses/misunderstood findings has not changed over several decades despite the increase in imaging modalities and studies:

1. Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F. Diagnostic errors in three medical eras: a necropsy study. Lancet. 2000; 355(9220):2027-31.
2. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21):2849-56.
3. Pastores SM, Dulu A, Voigt L, Raoof N, Alicea M, Halpern NA. Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients. Crit Care. 2007; 11(2):R48
4. Wittschieber D, Klauschen F, Kimmritz AC, von Winterfeld M, Kamphues C, Scholman HJ, Erbersdobler A, Pfeiffer H, Denkert C, Dietel M, Weichert W, Budczies J, Stenzinger A. Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in East and West Berlin. PLoS One. 2012; 7(5):e37460.

Autopsies aren't billable but are covered by various payments to the institutions (hospitals) because they play a role in QA and QI activities. Our failure to educate other physicians about the importance of autopsy in understanding disease, understanding course for individual patients and understanding poor outcomes lies at the heart of much of the discussion which has already occurred here. With the increasing frequency of patients to have been involved in clincial trials (oncologic, cardiovascular, etc), the need to assess the distribution and character of pathologic processes post-treatment has taken on an increasing role. This is not a role for which forensic pathologists are trained. In fact, this type of activity should be a critical position for the pathologist in the health care delivery system, rather than simply anonymously rendering diagnoses as a simple interface between a glass slide and an electronic document. When seen as a critical player in understanding health outcomes, the pathologist becomes an increasing important member of the community -- this will be the key to gaining an appropriate share of resources when reduced reimbursements are being distributed within Accountable Care Organizations.

What you are describing sounds more like research than patient care. Autopsies for "clinician education" and "understanding of disease" sound like a very big waste of pathologist time. PhDs should be doing that kind of stuff. Maybe if pathologists stopped doing autopsies, more strong medical students would go into pathology.

 

[Thrombus]

Long time lurker but felt the need to surface in order to comment here:

Data exists that autopsies are not particularly detrimental to defense of malpractice suits at therefore should not be avoided to "protect other clinicial services":

Bove KE, Iery C; Autopsy Committee, College of American Pathologists. The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions. Arch Pathol Lab Med. 2002 Sep;126(9):1023-31. Review. PubMed PMID: 12204050.​

Data exists that the rate at which autopsies detect missed diagnoses/misunderstood findings has not changed over several decades despite the increase in imaging modalities and studies:

1. Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F. Diagnostic errors in three medical eras: a necropsy study. Lancet. 2000; 355(9220):2027-31.
2. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21):2849-56.
3. Pastores SM, Dulu A, Voigt L, Raoof N, Alicea M, Halpern NA. Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients. Crit Care. 2007; 11(2):R48
4. Wittschieber D, Klauschen F, Kimmritz AC, von Winterfeld M, Kamphues C, Scholman HJ, Erbersdobler A, Pfeiffer H, Denkert C, Dietel M, Weichert W, Budczies J, Stenzinger A. Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in East and West Berlin. PLoS One. 2012; 7(5):e37460.

Autopsies aren't billable but are covered by various payments to the institutions (hospitals) because they play a role in QA and QI activities. Our failure to educate other physicians about the importance of autopsy in understanding disease, understanding course for individual patients and understanding poor outcomes lies at the heart of much of the discussion which has already occurred here. With the increasing frequency of patients to have been involved in clincial trials (oncologic, cardiovascular, etc), the need to assess the distribution and character of pathologic processes post-treatment has taken on an increasing role. This is not a role for which forensic pathologists are trained. In fact, this type of activity should be a critical position for the pathologist in the health care delivery system, rather than simply anonymously rendering diagnoses as a simple interface between a glass slide and an electronic document. When seen as a critical player in understanding health outcomes, the pathologist becomes an increasing important member of the community -- this will be the key to gaining an appropriate share of resources when reduced reimbursements are being distributed within Accountable Care Organizations.

Let me know when clinicians and hospitals have the time and money for more QA/QI activities that have enormous cost/benefit ratios.

 

[Virchows_Archive]

What you are describing sounds more like research than patient care. Autopsies for "clinician education" and "understanding of disease" sound like a very big waste of pathologist time. PhDs should be doing that kind of stuff. Maybe if pathologists stopped doing autopsies, more strong medical students would go into pathology.

While improving clinical care and patient outcomes through assisting those caring for patients and those running clinical trials can be considered "research" it definitely belongs in the domain of the pathologist physician rather than the PhD. From your perspective, the PhD who synthesizes a new compound should lead the clinical trial because it isn't "real patient care". In fact, the lack of interest in pathology among students stems in large part from the focus of much of the community on the "move the glass" mentality rather than the intellectual value which pathologists bring to the table. If all you do is sign out cases and e-mail reports, you might as well be in a dark cave in an obscure location -- and that isn't attractive to medical students.

Sorry but narrow-mindedness of "what I do is all that matters in pathology" got me pulled into the pointless discussions about the downward spiral of the discipline which have characterized this group for years. It is only declining for those with narrow vision. Back to lurking and (quietly) feeling sorry for those who are so unhappy with their lives.

 

[Substance]

While improving clinical care and patient outcomes through assisting those caring for patients and those running clinical trials can be considered "research" it definitely belongs in the domain of the pathologist physician rather than the PhD. From your perspective, the PhD who synthesizes a new compound should lead the clinical trial because it isn't "real patient care". In fact, the lack of interest in pathology among students stems in large part from the focus of much of the community on the "move the glass" mentality rather than the intellectual value which pathologists bring to the table. If all you do is sign out cases and e-mail reports, you might as well be in a dark cave in an obscure location -- and that isn't attractive to medical students.

Sorry but narrow-mindedness of "what I do is all that matters in pathology" got me pulled into the pointless discussions about the downward spiral of the discipline which have characterized this group for years. It is only declining for those with narrow vision. Back to lurking and (quietly) feeling sorry for those who are so unhappy with their lives.

I disagree. The autopsy ritual has outlived its usefulness. I cannot see how doing more autopsies will be helpful in the future, what with imaging and medical understanding being at the point it is at.

Your comparison with clinical trials is not accurate. Clinical trials are something done in addition to medical practice, not to mention they have the potential of adding both care value and financial value to patients and corporations respectively. They are also direct patient care activities. Autopsies, as you suggest, would be done as the primary focus of the physician, and benefit "knowledge' and "research" but not the patient directly. And yes, decisions about direct patient care is why physicians are physicians and not PhDs - their actions have direct consequences on people's lives.

It's funny that you mention that autopsies will allow pathologists to "bring more to the table" out of the "dark cave in an obscure location", yet autopsies are performed in the darkest, most obscure regions of hospitals.

I doubt many think pathologists bring much intellectual value to the table. The lowest of the low can get into pathology. Doesn't say much for the specialty.

Know what isn't attractive to medical students? Dead bodies and Rokitansky gore rituals, and being a peripheral participant in patient care. Know what is? The pride of knowing that you're making a direct - hear that, direct - difference in someone's life. All else is merely research, and yes, PhDs can do that just fine. There is nothing more peripheral to direct patient care than the autopsy. Nothing is directly at stake.

The thing about the autopsy is that, like most rituals, it is adhered to religiously by its acolytes without paying any mind to detractors, however logical they may be.

 

[BlondeDocteur]

Well here I feel able to comment intelligently, having been a clinical resident. I cannot tell you how many times that we the clinical team have wanted an autopsy, or at least wanted the definitive answer that an autopsy can provide, and had difficulty procuring one (even in an academic hospital with a great pathology residency program). It didn't happen every day, or every week, but at least once a month I found myself really wanting to know. On the rare occasions when we did have a hospital autopsy and the pathology resident could actually be bothered to come to our M&M (6:30 AM for surgery, not so attractive for path residents) it was phenomenal. There were often medicolegal dimensions to what was discovered but mostly it was immensely intellectually satisfying to finally get that definite answer. Personally I felt nothing but respect for the pathologist when they presented; I wasn't sitting there pitying them that they were arm-deep in a bloated corpse or something.

And actually it was performing autopsies themselves that really solidified my interest in pathology. When I did my path elective as a R2 the pathologists all teased me because I approached autopsy "like a surgeon"-- that is, I was sl-oo-ooo-oow-- because I thought it was so phenomenal to get such amazing access to every structure in the human body. I did these really intricate tedious dissections of everything. It was better than being in the OR when you had to worry about hemostasis and collateral damage, and it was a hell of a lot better than hacking around on a dessicated embalmed body in the cadaver lab as an MS1. As everyone here knows I'm very interested in pediatric pathology, which has a decent # of fetal, perinatal and pediatric autopsies. I've seen beautiful dissections and these marvelous morphologic analyses come out of autopsy studies. Yes it's a "19th century science" in the narrow sense that the gross techniques were first developed then, but does that really mean there have been no advances or the current toolbox in modern medicine cannot symbiotically benefit from autopsy findings? I honestly don't know, I'm asking.

I might be the odd one out as I am obviously someone who liked pathology enough to switch over to it, and I like gross anatomic pathology in particular. I do think that the respect which is bestowed on path as a field is predicated on its reputation as an intellectual, 'doctor's doctor,' definitive-answers field. Being able to give the final word on a patient's disease processes via autopsy seems like a good part of that reputation.

 

[Substance]

Well here I feel able to comment intelligently, having been a clinical resident. I cannot tell you how many times that we the clinical team have wanted an autopsy, or at least wanted the definitive answer that an autopsy can provide, and had difficulty procuring one (even in an academic hospital with a great pathology residency program). It didn't happen every day, or every week, but at least once a month I found myself really wanting to know. On the rare occasions when we did have a hospital autopsy and the pathology resident could actually be bothered to come to our M&M (6:30 AM for surgery, not so attractive for path residents) it was phenomenal. There were often medicolegal dimensions to what was discovered but mostly it was immensely intellectually satisfying to finally get that definite answer. Personally I felt nothing but respect for the pathologist when they presented; I wasn't sitting there pitying them that they were arm-deep in a bloated corpse or something.

And actually it was performing autopsies themselves that really solidified my interest in pathology. When I did my path elective as a R2 the pathologists all teased me because I approached autopsy "like a surgeon"-- that is, I was sl-oo-ooo-oow-- because I thought it was so phenomenal to get such amazing access to every structure in the human body. I did these really intricate tedious dissections of everything. It was better than being in the OR when you had to worry about hemostasis and collateral damage, and it was a hell of a lot better than hacking around on a dessicated embalmed body in the cadaver lab as an MS1. As everyone here knows I'm very interested in pediatric pathology, which has a decent # of fetal, perinatal and pediatric autopsies. I've seen beautiful dissections and these marvelous morphologic analyses come out of autopsy studies. Yes it's a "19th century science" in the narrow sense that the gross techniques were first developed then, but does that really mean there have been no advances or the current toolbox in modern medicine cannot symbiotically benefit from autopsy findings? I honestly don't know, I'm asking.

I might be the odd one out as I am obviously someone who liked pathology enough to switch over to it, and I like gross anatomic pathology in particular. I do think that the respect which is bestowed on path as a field is predicated on its reputation as an intellectual, 'doctor's doctor,' definitive-answers field. Being able to give the final word on a patient's disease processes via autopsy seems like a good part of that reputation.

Therein lies the question: is wanting to know reason enough to pay for one?

By that extension, is wanting an MRI to see the brain because of the occasional headache enough reason to do one?

Most of the autopsies that my team has had the displeasure of procuring have been CV-related deaths. No surprises. Even if we did find a surprise, what would that do other than be "a cool case"?

 

[BlondeDocteur]

What's the point of case reports period? Enough anecdotal observations compound into a hypothesis compound into a study question compound into significant advancement of medical knowledge/ change in patient care.

I have a positive story and a negative story on both sides of the coin here, but both support my feeling that autopsies are extremely useful for patient care.

Positive story: intraoperative death with no suspicion for cardiac event but in a high ASA Class patient (so no automatic forensic autopsy), during a procedure with very low antecedent risk (diagnostic mediastinoscopy). Surgeon extremely worried re: technique. On autopsy surgeon's fears re: technique were verified. Surgeon made dramatic change to technique for this particular procedure and taught new change to cardiac fellows and GS residents. Surgeon published case report on new technique.

Negative story: ICU death of young patient with multiple comorbidities and a catastrophic intraabdominal infection. Patient had been taken to OR multiple times for local debridements and washouts, had open abdomen, the works, with no obvious reservoir of infection seen. Surgical team very puzzled about death given that the patient was young and should have recovered. Surgical team requested autopsy with specific interest in dissecting the fascial planes of the abdomen and groin to assess for occult nec fasc (labs somewhat consistent with nec fasc but clinical exam not convincing, and healthy tissue was seen on debridement). Autopsy performed in rote standard Rokitansky manner with no attention paid whatsoever to the surgical team's request (massive Y-incision by diener, etc). Question not answered. But it could have been extremely useful in terms of feeding back into our treatment of soft tissue infections superimposed on a surgical site/intraabdominal infection.

 

[turtle1966]

Sorry but narrow-mindedness of "what I do is all that matters in pathology" got me pulled into the pointless discussions about the downward spiral of the discipline which have characterized this group for years. It is only declining for those with narrow vision. Back to lurking and (quietly) feeling sorry for those who are so unhappy with their lives.

I was trained at a time and at a place where Autopsy was highly regarded in and out of our Institution. For me Autopsy was good for initiation in Pathology and that was it. After my residency, I have so far done less than a dozen, as a bystander, all performed by a PA. ALL wast of time.

From your writing, I gather you are an Academician of importance and passionate about autopsies. My hat is off to you. However, I feel that you are seriously out of touch with the real world:

1-I do not think that medical errors will be reduced by more autopsies.
2-I have noticed those passionate about autopsies often project onto others the same passion; however, most of us do not like it, we just tolerate it because we are forced to.
3-It does not pay, it is gory, time-consuming, and in spite of your stat quotes, positives do not count in real world, the negatives do, i.e., it takes only one negative finding towards a medical staff or hospital to hurt your career.
4-In a perfect world, we should have an important role in ACA, however, absolutely not through autopsies.​

Your ideas is very reminiscent of Dr. Roger Smith, chairman of U. of Cincinnati, circa 1980-90, who used to preach autopsy as future of pathology.

Those in Academia should learn (and very quickly) that, unless, financial well being of any specialty is taken care of FIRST, that specialty will have a future as bright as that of Shakers. It is an idealistic folly to think that the quality will precede financial well-being; in this regard, our specialty is struggling just to keep its head above the water, thanks to Academic dons.

 

[Substance]

What's the point of case reports period? Enough anecdotal observations compound into a hypothesis compound into a study question compound into significant advancement of medical knowledge/ change in patient care.
I have a positive story and a negative story on both sides of the coin here, but both support my feeling that autopsies are extremely useful for patient care.
.

A case report does not require more professional work and expense; it is merely a retelling of facts. In contrast, an autopsy is an expensive procedure of no benefit to the patient and of marginal benefit to medicine as a whole. Given the cost of medicine, we have no choice but to select what is important and what is less so - we do not have the resources to do everything. Autopsies are at the bottom of the list, which explains why they have essentially disappeared in most institutions.

Again, if autopsies are purportedly the domain of the pathologist, then we are clearly overpaying for them. PhDs should do that work at 80k a year since patients are not at individual risk due to them being dead. If I were a pathologist forced to do autopsies I'd be pretty angry and feel as if my time is not valued, since there are about a million better ways for a pathologist to spend his or her professional time than carving up the dead.

I've found even more accounts of patients going to X hospital for a probably minor complaint, seeing X doctor who does not order high-end imaging on them, only for them to die or be disabled soon after. With that being said, let's open up the MRI machines to everyone, since we could miss something if we don't, and we need to learn, and what better way to learn than to see evolution of findings while the patients are still alive. But you and I both know this is crazy talk.

I've thought that if a surgeon or other doc is interested in post-mortem findings, they could perform the autopsies. They'd certainly learn more from doing it themselves than just reading a boilerplate report from a basement-dwelling English-non-fluent pathologist. If its so important then they should make time for it.

 

[turtle1966]

I have a positive story and a negative story on both sides of the coin here, but both support my feeling that autopsies are extremely useful for patient care.

My opinion that autopsy is useless is for community practice and not for academic practice. There is a huge difference between academia and community practice.

To be maximally beneficial, autopsies should be a joint venture between the ordering clinician and performing pathologist. The ordering should be physically present throughout an autopsy, present clinical history and give his input during the post. As currently done, pathologists are acting more like a cook at a McDonald joint.

 

[mlw03]

My opinion that autopsy is useless is for community practice and not for academic practice. There is a huge difference between academia and community practice.

To be maximally beneficial, autopsies should be a joint venture between the ordering clinician and performing pathologist. The ordering should be physically present throughout an autopsy, present clinical history and give his input during the post. As currently done, pathologists are acting more like a cook at a McDonald joint.

Interesting analogy. I can recall 1 instance from residency when an attending physician came to the autopsy to see what the findings were. Again, comes down to money I think. Surgeon makes lots of money performing a whipple, but makes zilch spending 2 hours down in the dungeon participating in an autopsy.

We can all debate this all we want. The ABP will do what it wants and we'll have to deal as a pathology community. WHEN (not if) the ABP fully drops the autopsy requirement, it'll just be a matter of time before non-forensic pathologists entirely stop doing autopsies.

 

[turtle1966]

Again, if autopsies are purportedly the domain of the pathologist, then we are clearly overpaying for them. PhDs should do that work at 80k a year since patients are not at individual risk due to them being dead.

Because I have watched by old teachers perform autopsies and interpret the findings, I know that PhDs are not capable of doing autopsies.

Autopsy is an art and summation of your expertise in pathology. You have to know temporal evolution of multiple diseases and their gross morphological tissue manifestations in order to interpret the findings and arrive at a valid conclusion. It is not cut and slice manual labor. Many clinicians do not know this, unfortunately.

I've thought that if a surgeon or other doc is interested in post-mortem findings, they could perform the autopsies.

They should have a more active participation in autopsies. They use their political clout to support politically and financially autopsy services as well.

The ABP will do what it wants and we'll have to deal as a pathology community.

The ABP, to best of my understanding, is run by ancient, hoary, deans of pathology. So, I think Autopsy in Academic setting will be safe.

 

[turtle1966]

And actually it was performing autopsies themselves that really solidified my interest in pathology. When I did my path elective as a R2 the pathologists all teased me because I approached autopsy "like a surgeon"-- that is, I was sl-oo-ooo-oow-- because I thought it was so phenomenal to get such amazing access to every structure in the human body.

That is a passionate declaration of love for pathology. You will be a Great pathologist!!

 

[Thrombus]

Sorry but narrow-mindedness of "what I do is all that matters in pathology" got me pulled into the pointless discussions about the downward spiral of the discipline which have characterized this group for years. It is only declining for those with narrow vision. Back to lurking and (quietly) feeling sorry for those who are so unhappy with their lives.

Hurling insults at others is hardly a good way to engage others in your thoughts. I have yet to see or hear of a place where the whole medical team participates in an autopsy conducted by the pathologist. Too often I find academics living in some sort of utopian universe. Maybe this happens at your place and everyone benefits somehow in the QA/QI. All places I have been, there is no time for clinicians to participate and no money for pathologists to participate.

I also find your comments about those in community pathology as being some sort of automated robot pushing glass revealing. Maybe now is the time for you to do some introspection as you clearly are too insulated and perhaps you are projecting narrow mindedness for a reason? Then to claim that people are unhappy in their careers because they only "push glass and type reports"? No, there is unhappiness because there are TOO DAMN MANY OF US AND NOT ENOUGH WORK TO DO AND CORPORATE SUITS AND OTHER PHYSICIANS TAKE ADVANTAGE OF THIS AND SCALP OUR PAYCHECKS. ACADEMIA REFUSES TO CUT OFF THE SPIGOT BECAUSE THEY ARE SUBSIDIZED GREATLY BY TRAINEES AND THEIR FREE LABOR.

There, maybe now you can get the message.

 

[turtle1966]

WHEN (not if) the ABP fully drops the autopsy requirement, it'll just be a matter of time before non-forensic pathologists entirely stop doing autopsies.

Have you heard of virtual autopsy? I watched a documentary video on FP pointing out several advantage over physical autopsy? Obviously if tissue is needed, it would not work.

 

[mlw03]

Have you heard of virtual autopsy? I watched a documentary video on FP pointing out several advantage over physical autopsy? Obviously if tissue is needed, it would not work.

Yes, I have heard of virtual autopsies. I don't believe in them as an autopsy replacement. At best, I see them as an adjunct. Again, it comes to money. Medical examiner and coroner offices have enough trouble finding money to pay pathologists an adequate salary, so I don't see CT scanners becoming common (there are 3 civilian offices that have them at present - UNM, Maryland, and Toronto).

In the academic setting, maybe there's a place for it, but again, who's going to pay the radiologist to interpret a full body CT scan (it takes a few hours to be done right)? Why would radiologists be interested in getting involved in this when there's no money to be made?

 

[turtle1966]

Yes, I have heard of virtual autopsies. I don't believe in them as an autopsy replacement. At best, I see them as an adjunct. Again, it comes to money. Medical examiner and coroner offices have enough trouble finding money to pay pathologists an adequate salary, so I don't see CT scanners becoming common (there are 3 civilian offices that have them at present - UNM, Maryland, and Toronto).

In the academic setting, maybe there's a place for it, but again, who's going to pay the radiologist to interpret a full body CT scan (it takes a few hours to be done right)? Why would radiologists be interested in getting involved in this when there's no money to be made?

From what I observe from my vantage point, private FP groups that I know appear to be prospering in US.

If PAs can do autopsies, there must be CT techs to run CT machines. In the documentary, the guys interpreting virtual autopsies were not radiologists, but FPs.

Do I see an opportunity for FP in the future? Yes, I do but you guys would need to do some PR to educate population at large as to the sad state of FM.

 

[2121115]

... because there are TOO DAMN MANY OF US AND NOT ENOUGH WORK TO DO AND CORPORATE SUITS AND OTHER PHYSICIANS TAKE ADVANTAGE OF THIS AND SCALP OUR PAYCHECKS. ACADEMIA REFUSES TO CUT OFF THE SPIGOT BECAUSE THEY ARE SUBSIDIZED GREATLY BY TRAINEES AND THEIR FREE LABOR.

Well, um, yeah... this.