Autopsy - More? Less?

[WhtsThFrequency]

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A quote from another thread, but I thought I'd pose the question to you guys because it make me wonder

But Atul Gawande in one of his books seems to bemoan the increasing refusal of families and individuals to perform autopsies and the choice by many doctors to not have them done. He suggests that leads to a lack of quality control of sorts in that physicians can't determine whether or not the patient died from an incorrect diagnosis or treatment just wasn't effective. Something to chew on.

Do you think there is a lack of autopsies? Do you think medical care, in severe disease situations, might be changed if more were performed in order to see if anything went wrong or if some treatment could be improved?

In addition, how many autopsies do you actually do as a human pathologist? I read on another thread that about 50 are required to sit for boards, and generally it's a small part of any AP job - true? Admittedly I don't know much about the human pathology side - I'm in veterinary anatomic pathology, so full necropsy (ranging from 20-30 per week when you're on the floor) and doing the subsequent histology is a huge part of what I do, with biopsy trailing. But you guys, I am sure, get a ridiculously greater amount of biopsy than I (jealous 😉 - we all love to figure out what happened, but having input on a living/current case is often better). Do you wish autopsy was more common?

 

[KCShaw]

There are actually a number of articles addressing this topic. According to one, in 1971 JCAHO dropped its requirement for hospitals to maintain a minimum autopsy rate on deaths in accredited institutions. Another site reports that in the 1940's the autopsy rate was about 50%, while today it's around 5%. To top it off, give or take a quarter of autopsied hospital cases reveal "significant" disease or complication not previously diagnosed. (Those are roughly in line with my recollection of various academic publications, without having tracked them all down again.)

It's not clear to me, however, that anyone has translated that into whether increasing the autopsy rate would save money systemically. And money, I think, is where it's at these days.

Similar cycles of autopsy rates could probably be traced into history, though probably primarily influenced more by waxing and waning religious, societal, and academic trends. In modern times, IMO it's money. Hospital & academic pathologists generally do not get reimbursed for hospital autopsies, and the hospital itself doesn't, but may spend hours to days on one between chart reviews, dissection, histology, phone calls, and report writing, and for the hospital, disclosure of recognized clinical misses or mistakes. In private practice, families generally can't afford the $2-5000 it may cost to have one performed, and frankly most pathologists would rather crank through their daily slides than run around dealing with an autopsy -- particularly when their entire practice may perform <50 per year, and many perform none at all. A far cry from 20-30 veterinary cases per week, mixed in with your regular work; by comparison, for a medical examiner office to be accredited by the National Association of Medical Examiners they must have enough FP's vs case load that no one FP would "have" to perform >300 cases/yr (external exams count, but at a fraction of 1, I believe it's written as 3-5 externals count as 1 autopsy, so most people just use 4), but the recommendation is not to exceed 250/yr.

Currently, IMO academic autopsies survive primarily because of residency requirements (I believe it's still required to perform or share in 50 during all of residency), though those requirements have trended to increased laxity. Forensic and private autopsies aren't going anywhere, but each usually have somewhat restricted goals and typically do not involve clinician feedback even if a clinician was ever involved.

As for the original quote, keep in mind that doctors cannot "order" an autopsy like they can "order" an x-ray. The best can do is make a request to the next of kin, who then has to sign a consent. But, doctors (& hospitals) sometimes seem to have a sort of fear of autopsies, as if finding something they didn't recognize is equivalent to being found guilty of a crime and loss of their job and licensure.

I doubt the situation in academic/hospital autopsies is going to reverse without a monetary influx, which is unlikely to happen without some documentation that it could save the system money. Already in places that do them regularly there is not always formal feedback to clinicians or appropriate complete academic integration -- i.e., few really benefit except the path residents getting their numbers, which is somewhat beside the point.

 

[WhtsThFrequency]

True, financial issues really play a part. For us, some institutions charge producers and owners for necropsy, and some do not. Obviously the caseload is much higher at those that don't - but considering the current economic situation at academic institutions, that may become a thing of the past. Even the extra 50 to 100 dollars we charge for a necropsy plus histology could help out the hospital, considering how many we do. Damn...I didn't realize human autopsy cost so very much - makes a lot more sense now why many people can't have it done. Add in the old feelings of social taboo and I can see the low prevalence.

And your mention of the whole potential legal aspect of it is worthwhile too. Obviously, the risk of findings leading to (false) malpractice suit is very real. To clarify, I'm speaking more to the the litigious society we live in, not that doctors are doing anything wrong or "hiding" anything. If people can glean some sort of issue from a necropsy report and turn it into a suit - badness, and people are MUCH more apt to vengefully do that in human medicine versus vet (although suits are gaining traction in expensive animals). So I can definitely see why institutions are not banging down the door to do them.

Do you think autopsy will eventually be phased out of residency requirements? From what I've been gathering, is just doesn't seem to be worthwhile to the average pathologist unless they decide to go forensic. But that's my opinion, does anyone think that autopsy work should remain the same or even more exposure given if financial and social constraints were lessened?

Sorry if I'm boring anyone by pushing the question 😳 - I debated for a long time whether to go med or vet, so I still retain a great interest in the human path world and how it differs.

 

[2121115]

....there is not always formal feedback to clinicians or appropriate complete academic integration -- i.e., few really benefit except the path residents getting their numbers, which is somewhat beside the point.

I echo this. Hospital (or "medical") autopsies are for educational benefit of medical students and residents. They have very little to do with diagnosis or providing clinicians with information that they don't already know. Of the autopsies that I did in residency, when I would speak with the clinician it was uncommon that they were interested in getting a medical autopsy and they often did not even know it was being performed.

Forensics is a different matter.

 

[KCShaw]

Yeah..we typically only got much interest from the pediatricians and pediatric geneticist. Most other clinical M&M's actively excluded us, or claimed that since they were having their presentation the next day they could just read our prelim (a few bullet points of the main findings) and that would be fine, or even our own attendings would suggest to us not to go since our report wasn't complete yet and GOSH who would want to talk about an incomplete report? Unfortunately logistically we couldn't just show up to all the M&M's prepared with every autopsy we'd done over the last couple of months just in case they were going to talk about it. To make it more frustrating there was a tendency to ask us things they hadn't mentioned prior to the autopsy, so we didn't focus on it. I seriously doubt anyone in those groups went back to read the final autopsy report, minus very rare exceptions. Which translates into yet more lack of understanding of what an autopsy can or can't do for a clinician and ultimately for the living.

For those not in human pathology, there is a strong undercurrent of distaste of autopsies among most surgical pathologist attendings, which commonly oozes onto residents.

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Damn...I didn't realize human autopsy cost so very much - makes a lot more sense now why many people can't have it done. Add in the old feelings of social taboo and I can see the low prevalence.
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Do you think autopsy will eventually be phased out of residency requirements? From what I've been gathering, is just doesn't seem to be worthwhile to the average pathologist unless they decide to go forensic. But that's my opinion, does anyone think that autopsy work should remain the same or even more exposure given if financial and social constraints were lessened?
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Cost and charge are different, but most of the private autopsy rates I've seen were in that 2-5k range. I think the lowest charge I've seen in the last 5 years is about $1100? I honestly don't know the average cost; we worked ours up for budget meetings but I wasn't directly involved in that process, and I'm sure it's different for academic centers rather than our ME office.

I seriously doubt it will be entirely phased out of path residency requirements. It's more likely to develop better integration with a return to broader utility than go away, IMO. As institutions continue to flail around for grant and research money, I suspect more will look to autopsies as a viable source for research projects. But it takes more than 1 person to drive and be successful with. If it does happen to fade away as a requirement, it's likely to significantly affect FP fellowships and by extension forensic practice, and with the recent NAS report and subsequent congressional rumblings to improve the broad field including all forensic sciences... I just don't see it happening. But, I'm not surprised by much anymore.