In Defense of Autopsy
The postmortem examination is a key aspect of training, research, and healthcare
Alison Krywanczyk, Elaine Amoresano, Leslie Anderson, Rebecca J. Asch-Kendrick, Sarah E. Avedschmidt, Amy H. Deeken, Tracy S. Halvorson, Kailee Imperatore, Nicole R. Jackson, Jamie E. Kallan, Anne M. Laib, Ashley Elizabeth Mathew, Judy Melinek, Catherine Miller, Jaime Oeberst, Deanna A. Oleske, Madeleine Opsahl, Maneesha Pandey, Susan Parson, Karen F. Ross, Yen Van Vo, Lindsey C. Thomas, Lee Marie Tormos | | Discussion
As pathologists who perform autopsies on a regular basis, we were alarmed by the recent publication of Hugh Wilson’s article. Many of his statements are objectively untrue and perpetuate pervasive negative stereotypes of pathology, specifically autopsy pathology. The editorial demonstrates Wilson’s lack of understanding of the autopsy procedure and its value. The autopsy is the gold standard for determining cause of death, plays a critical role in hospital quality assurance and improvement, and provides a mechanism for evaluating and improving patient care.
Contrary to Wilson’s assertions, pathologists do not “dismember” decedents during an autopsy examination and a correctly performed autopsy is not a disfiguring procedure. This is a common misconception that is easily remedied by observing an autopsy or receiving quality autopsy training during pathology residency. The autopsy is a medical procedure during which the decedent is treated with respect. Afterward, the decedent’s body can be viewed by family members and open-casket services can be held. Wilson’s assertion that most physicians have observed at least one autopsy examination is also incorrect; in fact, most medical students and residents will never observe an autopsy and, as a result, are less likely to advocate for or request an autopsy for their patients.
Additionally, autopsies are performed in a clean, procedural fashion; the examination is not “dirty,” “malodorous,” or “dangerous.” His description of the autopsy as a “barbaric anachronism lacking any real medical value” is reminiscent of the unscientific 17th- and 18th-century fear of dissection after death (1). It perpetuates the belief that a) the dead are “scary” or “icky” and b) the autopsy is unpleasant or uncomfortable for the deceased.
Wilson also fails to acknowledge the benefits of autopsy training for pathology residents. The autopsy is an essential educational tool that provides an opportunity to learn advanced dissection skills, improve gross descriptions, master normal anatomy, synthesize clinical histories, communicate findings with family members and other physicians, and draft complex reports. It also offers an opportunity to form a consultant relationship with other physicians and address any misconceptions they may have regarding pathology and the autopsy procedure.
Wilson’s statements that we learn nothing from autopsies and “very few people die without a known cause” are also incorrect. An extensive literature review is beyond the scope of this article, but there are many recent publications that reaffirm the autopsy’s value in detecting medical errors, identifying misdiagnoses or missed diagnoses, and refining clinical diagnoses. This remains true despite modern advances in imaging and diagnostic techniques. Overall, approximately five to 10 percent of medical autopsies identify a misdiagnosis that would have potentially impacted a patient’s prognosis, treatment, or survival (2,3). Among the most common misdiagnoses are pneumonia, pulmonary embolism, and undiagnosed malignancy. No oncologist would dare treat a patient’s rectal carcinoma based on imaging alone, without knowing the pathologic grade and stage from the resection specimen. Postmortem imaging can be a valuable ancillary tool, but can never replace the much more detailed and diagnostic information provided by an autopsy, the same way pre-mortem imaging cannot replace the vital contributions of biopsies and surgical resection specimens.
Furthermore, Wilson’s claim that the autopsy is “not healthcare in any form” is myopic and inaccurate by any definition of the term “healthcare.” The autopsy procedure is directly analogous to a visit with any physician. When we review the scene investigation report or medical notes, we are taking our patient’s history. When we perform the external and internal examinations, we are performing a physical examination. We often order additional laboratory testing, such as toxicology or vitreous chemistry, to clarify diagnoses. Thus, the autopsy pathologist is much like a family medicine physician for the deceased – the only difference is that we are performing their final examination and using the medical information we obtain to piece together the sequence of events leading up to death.
The autopsy is also defined by law as the practice of medicine in 20 states (4). Unfortunately, because of the heterogeneity of medicolegal death investigation systems in the United States, there are many examples of miscarried justice due to autopsies performed by unqualified medical professionals (5). One can only imagine the consequences if we delegated the task to non-pathologists or even non-physicians. The practice of autopsy fits squarely in the center of pathology; the autopsy pathologist must have a strong foundation in medicine and general pathology to interpret gross and microscopic findings, ancillary testing, and the course of events leading up to death.
We, as pathologists, all weather occasional jokes regarding our profession from colleagues and family; these experiences provide excellent opportunities to kindly correct popular misconceptions regarding the practice of pathology and our active role in patient care. Usually, it helps to have a good sense of humor about oneself, laugh with the person, and follow up with clarification and education. Unfortunately, there is no simple solution to the pervasive negative perceptions of pathology that are commonplace in medicine. Eliminating autopsy education from pathology training will not remedy these issues and may even exacerbate them. Improvements in perceptions of pathology, including autopsy and forensic pathology, can only be made through increasing exposure to pathology during medical education and consistently educating our colleagues and peers.
There are experiences as an autopsy pathologist that are entirely unique and among the most rewarding as a physician. To be thanked by the parents of a teenager after identifying an undiscovered heart defect; to see the proverbial “light bulbs” go off over clinicians’ heads when presenting autopsy findings at Morbidity and Mortality conference; to help a husband cope with guilt and grief after the death of his spouse, who suffered a massive gastrointestinal bleed in his presence – these are experiences that reaffirm our value and the value of the autopsy procedure to fellow physicians and the general public. In this way, our patients are more than just decedents. Our patients are also their families, the doctors who cared for them during their lives, and the prosecutors and defense attorneys who need to understand the autopsy findings in the pursuit of justice. It is rare as a doctor to have a position with such far-reaching impact; the possibilities are both humbling and motivating.
In conclusion, Hugh Wilson’s opinion piece was extremely disappointing to read. The opinions we as physicians share publicly, and the words we choose to express those opinions, are not inconsequential. We should use our voices to educate and reform public perceptions regarding the practice of pathology, and to help reject, not reinforce, the stereotypes against which our profession has struggled for years. We hope to have provided a more realistic, fact-based perspective for other pathologists and future pathologists. The autopsy is a classic, time-tested skill that is an essential component of pathology training and a culmination of the practice of medicine.
Any medical trainee who is considering a future in autopsy or forensic pathology, or is interested in learning more, is encouraged to join the National Association of Medical Examiners (NAME). NAME offers free membership for medical students and residents and hosts regular educational webinars.
- R Ward, “Introduction: A Global History of Execution and the Criminal Corpse,” A Global History of Execution and the Criminal Corpse. Palgrave Macmillan: 2015. Available at: https://bit.ly/3xRzG2w
- B Winters et al., “Diagnostic errors in the intensive care unit: a systematic review of autopsy studies,” BMJ Qual Saf, 21, 894 (2012). PMID: 22822241.
- HS Marshall, C Milikowski, “Comparison of clinical diagnoses and autopsy findings: six-year retrospective study,” Arch Pathol Lab Med, 141, 1262 (2017). PMID: 28657772.
- VW Weedn, MJ Menendez, “Reclaiming the autopsy as the practice of medicine: a pathway to remediation of the forensic pathology workforce shortage?” Am J Forensic Med Pathol, 41, 242 (2020). PMID: 32732591.
- R Balko, “The Fifth Circuit turns its back on a huge forensics scandal in Mississippi” (2014). Available at: https://wapo.st/39fZpYq.