Reinventing the Autopsy: CT Imaging as a Routine Part of the Procedure

A remark by Dr. Jared Schwartz during a lecture at the Futurescape Conference last June caused me to reflect on the possibility of reinventing the classic autopsy. At that time, he remarked that his department had installed an older model CT scanner in the autopsy room at Presbyterian Hospital in Charlotte, North Carolina. Pathologists in his department were using CT scans to supplement and enhance their autopsy findings. Germane to this same point, Dr. Michael Feldman noted in his lecture at the recent Molecular Summit that he uses CT images of surgically resected whole prostate glands as part of an ongoing research study on the integration of molecular data.

I believe that autopsies, as currently performed by pathologists, are inefficient from a work input-output perspective, ineffective as teaching tools, and a financial drain on pathology departments and hospitals because of insufficient reimbursement for the procedure. For various reasons including a lack of respect for the procedure on the part of clinicians and patient families, the autopsy rate in the U.S. has plummeted (see: The Decline in Autopsy Rates). Because of their infrequency, they no longer serve as an adequate teaching tool for medical students and residents. I therefore propose the following steps to reinvent the classic autopsy:

• Every autopsy should begin with a total-body, high-resolution CT scan performed by a technician in the autopsy suite. The CT images would be immediately interpreted by the responsible junior pathology resident (or diagnostic medicine resident; see below) with a senior pathologist providing oversight. For the purposed of this discussion, I suggest that name of the autopsy should be changed to catopsy because of this routine integration of imaging into the procedure.
• If and when any ambiguity arises about the CT findings or diseased/tumor tissue needs to be acquired (see next) or questions persist about the cause-of-death, minimally invasive techniques such as laparoscopy should be used to harvest the necessary tissues or to pursue any unanswered questions. Histological sections can be processed rapidly for microscopic examination, either using frozen or paraffin sections. In most cases, the final catopsy report for the majority of cases could and should be dictated in one to two hours and immediately transmitted to all treating physicians while the clinical findings are still fresh in their minds.
• Whenever possible, some of the harvested tissues would be submitted to a local or national biorepository. Some of the revenue from such biorepositories should be used to underwrite the cost of the catopsies. The accessibility of total body scans for all cases plus the associated clinical record would enhance the value of these tissue submissions to biorepositories.
• Given the above description of the catopsy, I predict that the permission rate would rise to encompass the majority of patients dying in hospitals. It would be explained to the patients' relatives that most of the procedures would involve only CT scans, that the tissue harvesting process would be minimally invasive, and would support medical research. The family members would also have the incentive of rapidly acquiring knowledge about the cause of death.
• I have been an advocate of merging the specialties of anatomic pathology, clinical pathology, and radiology into a new discipline of diagnostic medicine. The catopsy would be an ideal training tool for residents in this new field. They would have the opportunity to quickly correlate total body CT scans of most of the patients dying in a hospital with the histopathologic examination of relevant tissues and with ready access to the electronic medical record of the patient.

Comments

[Jared Schwartz MD PhD]

Bruce you are correct I have been preaching to pathologists, pathology educators and hospital leaders of the potential value of reinvigorating the autopsy using modern technologic tools. Imaging combined with Fine needle aspiration and the promise of molecular diagnostics could result in a minimally invasive autopsy or no autopsy in the traditional sense in some cases. Lets not forget other tools such as laproscopes. High resolution CT imaging for autopsy is occurring at a few research/military facilities in a few countries. Unfortunately i have not been able yet to convince our health system to be an alpha site for this procedure. We need to continue to try and educate healthcare leaders that a modern autopsy using all the tools available would without doubt renew the autopsy as an important part of improving the quality of health care. BUT unless a financial model can be developed to show the savings through improved outcomes few hospitals will invest in the research needed to demonstrate whether our belief of imaging improving the autopsy and autopsy rates is correct. I am an optimist and thus convinced that soon a few brave insitutions will step forward.

[Brian Jackson]

Bruce,

You have some great ideas in this blog, but this one in particular is an absolute winner. As a resident I despised autopsies because they're archaic and provide so little educational or medical value. I absolutely cringe when I see articles from pathologists claiming otherwise. Your proposal covers all the bases. I hope this idea gets some traction.

--Brian