Like clockwork, one sees periodic articles lamenting the decline of the classic autopsy like this one from the op-ed page of the New York Times (see: Bring Back the Autopsy). The usual argument cited in favor of a return to the preeminence of the autopsy is that it serves to identify diseases missed by clinical observation and imaging. In my opinion, these pieces will had little success in resurrecting the autopsy for the following reasons: autopsies are an unreimbursed activity so many pathologists prefer to devote their energies to reimbursed ones and don't actively campaign for an increase in autopies; clinicians may believe that today's sophisticated diagnostics identify most diseases antemortem; those clinicians who emphasize defensive medicine are happy to avoid a procedure that may highlight errors in care delivery; requesting an autopsy from grieving family members may be difficult for some physicians and junior hospital house officers; and, finally, healthcare consumers don't necessarily understand the merits of autopsies because they are becoming less frequent.
I have held the opinion for more than eight years that the adoption of the virtopsy might help to increase interest in the post-mortem study of the causes of death (see: Introducing the Virtopsy, a Variant of the Catopsy Theme; NYT Highlights the "Virtopsy" Used for All Military Autopsies; The Classic Forensic Autopsy on the Verge of Being Obsolete). Unfortunately, there is little enthusiasm for the virtopsy in this country even though it's far superior to the classic autopsy. I believe that the reasons for this are the following: (1) a reluctance to invest more capital in an unreimbursed and dwindling procedure; and (2) a reluctance on the part of pathologists, and particularly forensic pathologists, to promote a procedure for which they are currently untrained, which is to say the interpretation of post-mortem whole-body CT scans that are a key element of the virtopsy.
I believe that emerging interest in the molecular autopsy (i.e., post-mortem molecular testing) may rekindle interest in the classic autopsy which is defined in the following way (see: Molecular autopsy):
Molecular autopsy or postmortem molecular testing is a set of molecular techniques used in forensic medicine to attempt to determine the cause of death in unexplained cases, in particular sudden unexplained deaths (for example sudden cardiac death). About 30% of sudden cardiac deaths in young people are not explained after full conventional autopsy, and are classified as sudden unexplained deaths. The use of a panel of genetic markers for long QT syndrome, catecholaminergic polymorphic ventricular tachycardia and cardiac channel miopathies elucidated around 40 to 45% of the cases.
Healthcare consumers are increasingly aware of genomics and precision medicine. I propose that we now begin to promote molecular autopsies in hospitals, particularly teaching and research institutions, defined in the following way: a classic autopsy to determine the cause of death plus the harvesting of various tissues, including tumor tissue when present, to better elucidate genetic aspects of the disease(s) discovered or suspected. This effort should be tightly linked to the biobanking/biorepository program in the same or regional hospitals (see: Quest Diagnostics' Biorepository Receives CAP Accreditation).
This connection between biobanking and the molecular autopsy is very important because it not only advances science but provides the opportunity to possibly offset the incremental costs of molecular autopsies through tissue sharing. The opportunity is also presented by this means to engage research labs in the genomic testing associated with molecular autopsies at lower or no cost. None of this will happen overnight but I think that pathology is now being presented with a rare opportunity to reposition the classic autopsy as a key element in today's healthcare delivery system and precision medicine.