For ACGME case log, what counts as an autopsy?

[GooseIsland52]

Hey all - have been hearing different things regarding the ACGME case log for autopsies, specifically referring to fetuses. My current impression is that if it looks grossly human then it can be counted as an autopsy for "educational purposes" by the ACGME and can therefore be logged and counted. But, is there a certain gestational age cutoff that the ACGME looks for?

Thanks

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[Ombret]

My understanding of the situation:

Fetuses that show up as surgical specimens used to count as autopsies (?3+ years ago), but no longer do, regardless of gestational age. It makes sense, you are not really autopsying them, even though you throw a couple of organs into a cassette.

Anything that your hospital logs in as an actual autopsy can count. You must have been involved in all aspects of the case (gross, micro, report). Up to 2 residents can be on each one and it counts equally for both.

Forensic cases can count even though they are usually gross only and you are not usually involved in the report.

The ABP will not scrutinize your list all that closely and the ACGME will not scrutinize it at all, so a lot of this is left to your own discernment. By the way, the only data the ABP wants you to tell them when you apply for boards are age, sex, primary diagnosis, and date performed. They also want you to track how many were shared, restricted, forensic and fetal, but there are no specific guidelines on how many can be in each of these categories.

 

[KCShaw]

..snip..
Anything that your hospital logs in as an actual autopsy can count. You must have been involved in all aspects of the case (gross, micro, report).
..snip..

I think this is a fairly reasonable way to look at it. I would try very hard not to force the ACGME to define ages or numbers of organs looked at or numbers of micro slides looked at, etc. There's no need to encourage micromanagement. As it is one can argue that a forensic autopsy without microscopic examination "doesn't count", but practically speaking as long as you are involved in some way with the entirety of the case then you are learning something significant (including reasons why histology isn't always necessary, depending on the situation and the reasons for the autopsy). The same debate has gone on in regard to forensic pathology fellowships, where micro has/had (unless it's changed) to be done on at least 200 of your cases for the year.

If all of a sudden everyone starts reporting nothing but shared partial/restricted fetal autopsies, then that would probably force the ACGME to do something.

 

[gbwillner]

The simple answer is that an autopsy is "whatever your program director decides it is."

 

[yaah]

Just ask your program director. Fetus autopsies counted for us if they were over a certain age (24 weeks? I don't remember). Brain only cases did not. We could only count up to 10 forensic cases. There aren't any specific boards criteria.

 

[pathstudent]

I had a Limited liver biopsy only autopsy that me and one other counted as an autopsy. The whole thing is a bit of a farce.

Autopsy is a dying art. It is silly that you spend 4 to 6 months of your ap training covering autopsy when it comprises 0-2% of your actual service work for 98-100% of pathologists.

 

[GlassPusherJack]

I had a Limited liver biopsy only autopsy that me and one other counted as an autopsy. The whole thing is a bit of a farce.

Autopsy is a dying art. It is silly that you spend 4 to 6 months of your ap training covering autopsy when it comprises 0-2% of your actual service work for 98-100% of pathologists.

off topic but i agree- 1/8 of training looking at autolysis and working on the least likely thing to affect pt care or result in lawsuit (well for pathologist at least..)

back on topic is there a limit to # of shared autopsies?

 

[Autopsy101]

back on topic is there a limit to # of shared autopsies?

We have limited shared autopsies to 10. I thought this was based on ABP recommendation, but I guess it could be an internal, program-specific decision.

 

[Ombret]

ABP says nothing about it. 100% of your autopsies could be shared for all they care, by current standards. However if 100% of residents started doing this, I suspect that would rouse the sleeping dragon.

 

[yaah]

True - ABP says nothing except you need 50. They could theoretically all be limited to the pinky finger if your program allows it.

 

[KeratinPearls]

True - ABP says nothing except you need 50. They could theoretically all be limited to the pinky finger if your program allows it.

Pinky finger restricted autopsies! Sounds good to me.

 

[pathstudent]

Pinky finger restricted autopsies! Sounds good to me.

Shared by ten residents would be even better.

Autopsy is a relic. Forcing residents to do them and testing them on rise is equivalent to forcing anesthesia residents to memorize the dosage for ether.

 

[KeratinPearls]

Shared by ten residents would be even better.

Autopsy is a relic. Forcing residents to do them and testing them on rise is equivalent to forcing anesthesia residents to memorize the dosage for ether.

I wish we didnt have to do autopsies. I did 51 and am done. Yes, there are cases when autopsies are important (medicolegal asbestos/mesothelioma), but doing autopsies on patients who are trainwrecks makes no sense (renal failure, CAD, sepsis). Autopsies are a pain in the ***** and hopefully I dont have to do another one for the rest of my career.

I always wished for the cytogenetics only autopsies, but unfortunately never got one.

 

[Ombret]

Autopsy is not my cup of tea, but it is a huge part of the history of pathology and medicine and is the one thing that we undeniably own (cynics will say that no one else wants it...). So I would be sorry to see pathology as a whole lose interest in it. What I would love to see would be: (1) appropriate reimbursement for this complex medical procedure, (2a) a more efficiency-minded approach, (2b) streamlined reporting. All three of these things should be achievable, I would think.

 

[lipomas]

I wish we didnt have to do autopsies. I did 51 and am done. Yes, there are cases when autopsies are important (medicolegal asbestos/mesothelioma), but doing autopsies on patients who are trainwrecks makes no sense (renal failure, CAD, sepsis). Autopsies are a pain in the ***** and hopefully I dont have to do another one for the rest of my career.

I always wished for the cytogenetics only autopsies, but unfortunately never got one.

What does the ***** represent? Normally one gets a pain in their ass. If you are british it would be arse. I can conceive of a seven letter word also. Even a six letter word. But I can't think of a five letter curse word for this purpose. Pain in the penis?

 

[Enkidu]

off topic but i agree- 1/8 of training looking at autolysis and working on the least likely thing to affect pt care or result in lawsuit (well for pathologist at least..)

back on topic is there a limit to # of shared autopsies?

Are most autopsy tissues damaged by autolysis? I've only looked at brain histology from an autopsy and it seemed normal to me. Are brains less susceptible to autolysis?

 

[Ombret]

Are most autopsy tissues damaged by autolysis? I've only looked at brain histology from an autopsy and it seemed normal to me. Are brains less susceptible to autolysis?

GI, liver, kidney, pancreas, adrenal are particularly susceptible to autolysis; notionally, they lose protective mechanisms after death and proceed to digest themselves; but any tissue can show it; it depends on how long the person has been dead and what they died of (tissue from sepsis patients often looks like they've been "dead on the inside" for a while).

I think the point is that widespread autolysis in autopsy sections gives the lie our compulsion to put through a section of every organ for hospital autopsies. Your attending insists on a section of every organ, you turn what should really be a gross-only case into a two-tray extravaganza, and the report is delayed by two extra weeks while histology cuts the slides and you get around to reviewing them with your attending. And then the only micro diagnosis is "autolysis".

 

[HbyHA]

Autopsy is not my cup of tea, but it is a huge part of the history of pathology and medicine and is the one thing that we undeniably own (cynics will say that no one else wants it...). So I would be sorry to see pathology as a whole lose interest in it..

exactly! plus with new medical treatments/diagnostic come new ways that they affect the body that i can see at autopsy. We have "Therapeutic Complication" as a manner here, so i'm constantly getting these cases. i often speak with the treating physicians who find the information i give them helpful.

What I would love to see would be: (1) appropriate reimbursement for this complex medical procedure, (2a) a more efficiency-minded approach, (2b) streamlined reporting. All three of these things should be achievable, I would think

1- wouldn't that be nice?
2a/b: See forensics!

 

[pathstudent]

Autopsy is not my cup of tea, but it is a huge part of the history of pathology and medicine and is the one thing that we undeniably own (cynics will say that no one else wants it...). So I would be sorry to see pathology as a whole lose interest in it. What I would love to see would be: (1) appropriate reimbursement for this complex medical procedure, (2a) a more efficiency-minded approach, (2b) streamlined reporting. All three of these things should be achievable, I would think.

First off Medicare and insurance won't reimburse for medical work done on dead people. Historically autopsies are a service to the medical staff performed by pathologists for free. So the pathologist has no leverage in charging a high amount for an autopsy except in those cases where the family is demanding one.

 

[Ombret]

First off Medicare and insurance won't reimburse for medical work done on dead people. Historically autopsies are a service to the medical staff performed by pathologists for free. So the pathologist has no leverage in charging a high amount for an autopsy except in those cases where the family is demanding one.

Pathstudent, you are right. However, that doesn't mean there is not a parallel universe where payers value this service and do pay for it. With appropriate advocacy, maybe we can even enter that universe. I know, pathologists are not going to storm the Hill demanding payment for hospital autopsies. But if you dare to dream...

 

[KCShaw]

Insurance/medicare might take interest if there was reason to think it might save them money by altering hospital billing for that patient due to "incorrect" coding clarified by autopsy. I don't exactly favor that as a good reason, but still. And they might take interest if they chose to look beyond that individual patient and saw benefits in streamlining the expenses of the system to them as a whole. And they might have to take interest if it was recognized as a part of that patient's care -- the last medical examination they ever have -- as the requirements to fill out and sign a death certificate are already considered a patient care responsibility, even though the patient is deceased.

In modern history hospitals -had- to document a certain percentage of hospital deaths going on to autopsy; it was an accreditation requirement and integral part of quality control...as well as furthering medical knowledge. So the hospitals footed the bill generally by using their existing salaried or contracted pathologists. At one point that was a large part of how those acting as pathologists stayed busy and earned their keep. As surgical pathology grew and expanded, the demands on pathologists were stretched, and over a similar time society changed, non-pathologic (primarily imaging) and non-postmortem diagnostic methods expanded, and demand for autopsies decreased along with the requirement of hospitals to perform them. Autopsies were generally not separately paid or billed for because it was a hospital QC requirement (or was a forensic case handled by the state/county), not because they weren't considered useful to or a part of patient care.

 

[Enkidu]

In modern history hospitals -had- to document a certain percentage of hospital deaths going on to autopsy; it was an accreditation requirement and integral part of quality control...as well as furthering medical knowledge. So the hospitals footed the bill generally by using their existing salaried or contracted pathologists.

Why did this practice end? Was there a lobby of some kind? It seems like I read a statistic that a high percentage of medical autopsies performed today reveal results unknown to the clinicians... that would seem to indicate that routine autopsies could still play an important role in hospital QC.

Incidentally, mandatory routine autopsies might improve the job market for pathologists... even though most apparently aren't interest in doing them.

 

[pathstudent]

Why did this practice end? Was there a lobby of some kind? It seems like I read a statistic that a high percentage of medical autopsies performed today reveal results unknown to the clinicians... that would seem to indicate that routine autopsies could still play an important role in hospital QC.

Incidentally, mandatory routine autopsies might improve the job market for pathologists... even though most apparently aren't interest in doing them.

Would you rather do a autopsy or sign out a 100 gi biopsies. The autopsy pays nothing. A 100 gi biopsies will earn ten-fifteen k depending on the medicare/private insurance mix.

 

[Enkidu]

Would you rather do a autopsy or sign out a 100 gi biopsies. The autopsy pays nothing. A 100 gi biopsies will earn ten-fifteen k depending on the medicare/private insurance mix.

Well, if autopsies were mandatory for hospital accreditation then the hospital would have to pay pathologists to do them.

 

[raider]

Hospital Autopsies.... archaic and a waste of precious resources (with very few exceptions in which a "directed" biopsy may help clarify some questions)in an age where everyone gets imaged head to toe.

Instead of this stupidity, residents should spend more time in cytology, hematopathology and dermatopathology.

CP another total waste of time (with the exception of transfusion medicine). Unless we get reimbursed for micro, chem and all the other nonsense these should be phased out of path training.pHDs do this sh-t already so we are we wasting our precious time since the hospital can get a pHD cheap and make them take care of it (They can get any MD to sign-off on some of the bullsh-t). Molecular pathology has already been taken over by pHDs. Instead we should start doing procedures like biopsies etc. Once we have the expertise, the referrals will come (as we can tie on-site evaluation to our performing the biopsy and not do it for radiology etc.).Moreover, the people doing the interpretation are the best ones to decide what they want to see.We already do FNAS and bone marrow biopsies, why not introduce a "procedural fellowship". This is the "transformation" I believe in. Everything else is hogwash.

 

[Enkidu]

Hospital Autopsies.... archaic and a waste of precious resources (with very few exceptions in which a "directed" biopsy may help clarify some questions)in an age where everyone gets imaged head to toe.

But are they a waste of time because they don't serve their role as a quality check and educational tool for clinicians, or because they don't pay well for pathologists? If they are useful for QC then they should be mandatory. If they're mandatory then they should be compensated.

 

[raider]

(a) There are better measures of hospital QA/QC.

(b) As regards clinician education during mortality/morbidity conferences, again a directed sampling should be enough to answer most questions.

(c) Hospitals,where I have practiced, do not pay pathology departments for autopsies. You do it as a service to the hospital (usually in your contract). If you do "private autopsies" you do get paid though.


All in all a colossal waste of time (but isn't that true of a lot of what is taught in the medical school curriculum?).

 

[Enkidu]

(c) Hospitals,where I have practiced, do not pay pathology departments for autopsies. You do it as a service to the hospital (usually in your contract). If you do "private autopsies" you do get paid though.

But this is because of the contract negotiation. Pathologists are at a market disadvantage for the reasons outlined a million times in this forum.

If there were a much higher demand for pathologists because of mandatory autopsy requirements then pathologists would have much more bargaining power for autopsy compensation.

Of course, if autopsy truly does not benefit QC or clinician performance, then we shouldn't do it, but my impression has been that autopsy is very valuable but has declined due to liability concerns and changing accreditation requirements for hospitals.

 

[KCShaw]

A couple of the articles addressing autopsy in the manner under discussion:

1. R J Zarbo, P B Baker, and P J Howanitz, “The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions,” Archives of Pathology & Laboratory Medicine 123, no. 3 (March 1999): 191-198.
2. Chaido Spiliopoulou et al., “Clinical diagnoses and autopsy findings: a retrospective analysis of 252 cases in Greece,” Archives of pathology & laboratory medicine 129, no. 2 (February 2005): 210-4.

ASCP has partially addressed it as well; the statement also refers to JCAHO standards though not in as much detail as I would like, and comments that autopsy performance should be appropriately compensated:

http://www.ascp.org/pdf/Autopsy.aspx

I was unable to find current JCAHO wording in reference to autopsy on the joint commission website. As for why it's changed, there have been what amount to news articles guessing at it, but I don't know of a definitive answer being out there. That said, I suspect it's financial and comfort-zone related; institutions would rather not pay for something they get no monetary return on if they don't have to, while clinicians have been less and less likely to request autopsy consent from families as it becomes less and less of an accepted norm. Pathologists in general have less interest in something they get no direct compensation for and which can take an inordinate amount of time. So, there are a number of financial and political factors weighing against "hospital" autopsies being routine. I'm not aware of current literature weighing against them from a medical QC (including validated comparisons against modern imaging, pre-mortem or post-mortem), research, or educational point of view though I would grant exception as far as the time they require versus doing something else for a few hours. If someone knows of such published literature, please pass it along.

 

[earmuff]

Hospital Autopsies.... archaic and a waste of precious resources (with very few exceptions in which a "directed" biopsy may help clarify some questions)in an age where everyone gets imaged head to toe.

Instead of this stupidity, residents should spend more time in cytology, hematopathology and dermatopathology.

CP another total waste of time (with the exception of transfusion medicine). Unless we get reimbursed for micro, chem and all the other nonsense these should be phased out of path training.pHDs do this sh-t already so we are we wasting our precious time since the hospital can get a pHD cheap and make them take care of it (They can get any MD to sign-off on some of the bullsh-t). Molecular pathology has already been taken over by pHDs. Instead we should start doing procedures like biopsies etc. Once we have the expertise, the referrals will come (as we can tie on-site evaluation to our performing the biopsy and not do it for radiology etc.).Moreover, the people doing the interpretation are the best ones to decide what they want to see.We already do FNAS and bone marrow biopsies, why not introduce a "procedural fellowship". This is the "transformation" I believe in. Everything else is hogwash.

😱 I actually agree with Raider... Maybe that preacher was right. I should find god pronto!

 

[Narv007]

Has anyone here been audited by the ABP for autopsies? What's the minimum info we need for each case?

 

[MirkoCrocop]

Has anyone here been audited by the ABP for autopsies? What's the minimum info we need for each case?

I submitted a crappy little list with obvious errors and didn't hear a peep from the ABP. Of course, it probably helped that I gave them $2200 in the same sitting. They couldn't care less about your autopsies, only that that big fat check clears. It's a crooked business.

 

[KCShaw]

The ACGME online log has a number of fields to fill out, and that will give you most of the information you need. However, I seem to recall that the ABP application to take the AP boards requires some additional/different piece of information, and everyone in my program had to go back and dig up that information -- I just can't remember what it was, age or date of birth or something annoyingly simple like that.

No, they're probably not going to sit down and nitpick your list, although I suppose someone might, if say you or your program stood out for some oddball reason. It's not hard to set up a little excel file with the relevant fields and just track it as you go, though.

 

[member0007]

I have my up-to-dated log and it appears that I have more than the requisite cases. All the same, autopsies suck. Why? Well, it's the problem with pathology. Most pathologists won't do autopsies. wtf.

 

[KCShaw]

Reasons to do them are there, but the money generally isn't. And that's really about it.

 

[member0007]

Well, someone needs to contact people at ABP and the likes and let them know that it's nearly impossible to be reimbursed for autopsies. Also, when there are 24 residents and 100 to 300 autopsies, the average is anywhere from 4 to 12 autopsies per resident per year. Autopsies are not a waste of time; more cases should, if not all the cases should be redirected to medical examiner or something equivalent, so the rest of pathology can stop wasting time on stuff that is autolysed. FYI, not every residency has such a high incidence of autolysis related to their autopsies or surgical pathology specimens. It's just that some institutions do, but let's not point any fingers and/nor blame the leadership.

 

[mlw03]

Has anyone here been audited by the ABP for autopsies? What's the minimum info we need for each case?

I've never heard of anyone being audited. When I filled in the info a few years ago, I recall them wanting to know how many total, how many forensic, how many fetal, and how many shared. I don't remember ever filling in a specific list for each case.

 

[lipomas]

I think it depends on your residency program and what they decide to count. My program said we could only count up to 10 forensic cases. And we could only count up to 10 that were shared. But I know other people for whom the 10 forensic cases wasn't a limit, and others where basically all the autopsies were shared. When I took my boards the list did not indicated whether a case was limited, forensic, or shared. But I think they asked me how many were shared. Don't remember them asking me how many were fetal or forensic. Whether it matters or not I have no idea.

 

[KCShaw]

Sometimes the problem with forensic cases is that it's more difficult to accomplish all the other requirements ACGME has (the published requirements on acgme.org are evidently unchanged since 2007) in order to technically count them -- micros, being involved in cause/manner discussions, the final report, etc. etc. But, there is also a nonspecific requirement that residents have some exposure to forensic cases, pediatric cases, etc. In some ME offices a resident just isn't likely to be involved in everything on the checklist on every case, while in others they are, and programs have to decide how to handle that and have a reasonable explanation during ACGME inspections.