A Clinician Laments the Decline of the Autopsy

It may be time for me to print another lament about the decline of the autopsy as a follow-up to my blog note from August of this year (see: The Declining Autopsy Rate and an "Unattainable" Solution for the Problem). This new essay was written by Dr. Sandra Gompf who is an infectious disease specialist (see: A eulogy for the autopsy, and a call for its return). Here is an excerpt from it:

Evidence-based medicine and health insurers generally focus on what’s medically necessary, not what’s epidemiologically relevant, not what soothes the mind of the bereaved or of the physician grieved and mystified by the loss of a patient. Once, the autopsy was a venerated tool for medical advancement and humility. An invaluable means of learning one’s own limitations and the extraordinary diversity in nature and human physiology, it has now become an unreimbursed after-thought. An irrelevant thing, especially since the patient is already dead, there are living patients to care for, and people just need to “move on.” And it just doesn’t pay to know that your diagnosis pre-mortem was wrong; it only adds fuel to the malpractice attorney’s fire, which further fuels already skyrocketing malpractice insurance premiums. In life, a diagnosis based on assumptions is unacceptable. There are tests that must be run, high tech imaging, much probing and invading. Yet in death, an assumed cause is what goes on the death certificate well over 90% of the time....We should be thirsting for this knowledge, yet we throw away the opportunities to improve every day. I propose that the autopsy is more relevant than ever. That the dead can indeed live and speak through a thoughtful pathologist’s hands and eyes. That more than ever, doctors need to know what they are missing with all the bells, whistles, drugs, and treatment guidelines at their disposal. I have never found an autopsy on one of my patients to be less than a profoundly humbling and highly educating experience.

She's right, of course. There is only one good, and perhaps even better, substitute for the classic autopsy. That is the virtopsy, sometime referred to as the catopsy. With this latter procedure, a high-intensity CT scan is first performed on the deceased patient in order to identify and locate known, and unknown, pathologies. This imaging procedure is then followed by an abbreviated autopsy to confirm the CT findings and discover other lesions. The virtopsy is the standard of practice in the U.S. military (see: NYT Highlights the "Virtopsy" Used for All Military Autopsies) and in countries like Switzerland. You can acquire more details about the procedure from the University of Zurich virtopsy web site.

As far as I can tell from a Google search, the virtopsy has achieved little traction in the U.S. since I first began to write about it in Lab Soft News about three years ago. I attribute this lack of progress to the following: (1) most pathologist groups and departments give little thought to improving their autopsy service, viewing is as an unreimbursed activity used primarily for resident training and for cases when the cause of death is not obvious; (2) deployment of a virtopsy service requires extensive capital investment to purchase the CT scanner and remodel the autopsy suite; (3) broad acceptance of virtopsy programs would immediate render all pathologists, and particularly forensic pathologists, inadequately training to perform a key component of the virtopsy, interpretation of a CT scan; (4) there is no hue-and-cry or pressure from any portion of the medical, patient, or healthcare consumer community to move in this direction.

Comments

[Mark Pool]

Thanks, Bruce, for another provocative post on the autopsy. I guess I'll take the bait! The subject of this post reminds me of a saying I used to hear as a boy: "Two can live as cheap as one, if one don't eat." We talk the talk of wanting to improve quality, but the fact of the matter is that the autopsy (as it is currently) is a time- and energy-consuming endeavor whose value to medicine (as measured by its compensation) it exactly: zero. Encouraging more autopsies without reforming how our time is reimbursed is reckless and feckless--no matter what it contributes to education and/or quality. While I'm doing the autopsy for Dr. Gompf, she is likely seeing patients in clinic--meanwhile after I drag myself back to my office from the morgue, I still have trays of slides left that I have to sign out. Since I stand astride community and academic practices, I can also attest to the fact that autopsies are equally discouraged and demeaned even in teaching centers. If I hear any hue-and-cry for the autopsy (as things stand now), I'm running for the hills! With that being said, I agree that the virtopsy would be a brilliant alternative that actually would address several different problems and deficiencies (which can be deduced from your last enumerated points). This could be a ax-handle for our College to use if we seriously want to promote evidence-based medicine and improved patient care. As things are now, we get what we pay for.