Autopsy’s Swan Song

I read with interest, but no real surprise, your September article on the obstacles and challenges in pathology recruitment. Arriving amidst my retirement planning, it inspired me to reflect on my own experiences and what I have learned about the issue in over 30 years of pathology practice at a busy medium-sized community hospital and outpatient laboratories.

As your piece notes, there are multiple likely obstacles to pathology recruitment – here, from my perspective, I present the most significant.

Certainly, there is a lack of understanding of our specialty among medical school classmates and eventual colleagues. That deficit is a direct result of a curriculum that has no real-world exposure to the field while in medical school. As students, we all had hands-on experience in internal medicine and surgery, along with the associated subspecialties. I learned what internists and surgeons do and what their days might be like. But surgeons and internists have no real-world basis for understanding our work – and that lends itself to a sort of Dunning-Kruger effect whereby they believe they do.

The Dunning-Kruger effect is a cognitive bias in which people who are relatively unknowledgeable about a particular subject may overestimate their actual knowledge. Many of our classmates and colleagues have no hands-on knowledge of pathology; all they know is that we are not required to do a clinical internship, but are required to perform autopsies. Based on that limited knowledge, they believe in a pejorative stereotype – one that sees us arriving for work late, leaving early, and spending the day trawling the morgue for autopsies.

Autopsies and the lack of a clinical internship themselves are also major contributors to recruiting woes. From the day I first announced my residency choice to my medical school classmates, the taunts began.

“Pathology, eh? I hear they’re dying to get in there.”

“Pathology? Don’t you want to be a real doctor?”

An internship is a rite of passage for medical students – and is required to obtain a medical license. Renaming the first year of a pathology residency an “internship” is a semantic tool for meeting legal requirements, but hardly suffices as the capstone for a medical education. In the Army and Marine Corps, every specialist is a rifleman first. In medicine, every specialist should be a physician first – and that requires a true internship. Depriving medical students and prospective pathology residents of this rite deterred me and my classmates; I am certain it contributes to pathology’s recruiting difficulties.

The internship could be of the traditional rotating type or could be tailored to the needs of a pathology residency. I envision a customized residency with rotations in general internal medicine, general surgery, and the emergency department, along with additional rotations in the specialties we interact with most often: gastroenterology, urology, dermatology, oncology, pulmonology, head and neck surgery, gynecology, and neurosurgery.

Though the issue of the clinical internship is real, the autopsy is the 800-pound gorilla in the room. The image is so overpowering that our classmates can’t seem to look past it.

Studies consistently find respect and appreciation among the top factors leading to job satisfaction (or lack thereof). In my experience during residency and in daily pathology practice, I have found that we pathologists get little to no respect. We are the Rodney Dangerfields of medicine. Our colleagues see us not as “real doctors,” but as sub-doctors or super-techs – certainly not equals. Why? The autopsy.

The putdowns, thinly veiled as humor, continued throughout my residency and into my career.

“You don’t have to take a history. Your patients are all dead.”

“Your patients don’t talk back.”

When on the floor for a skin or bone marrow biopsy, “What are you doing here? The morgue is in the basement.” After noting I had moonlighted at a rural ER, “What – did they need an emergency autopsy?” Cue peals of laughter throughout the doctor’s lounge. The obstetrical colleague, who confided, “I wanted to go into pathology, but I didn’t want to be a mole downstairs in the morgue.”

All this even though autopsies constitute a tiny fraction of pathology practice. I hear the taunts from colleagues for whom I have never even performed an autopsy. Our classmates and colleagues simply can’t look past it. Many even seem to think that disposing of the dead is our responsibility. On multiple occasions, I’ve had colleagues call to ask me if their patient has died.

Why autopsy remains a part of pathology education is a mystery to me. An autopsy is not healthcare in any form. There is no care to offer the deceased. They are beyond our help. Our ministrations have failed them. Autopsy can be a research tool – and may have some value in family genetic counseling or law enforcement investigations – but it is certainly not healthcare. So why is it performed by physicians?

I ask that not as a rhetorical question. The very thought of an autopsy is a powerful and enduring image, not easily forgotten by those who have witnessed it. It evokes everyone’s natural fear of death and, among doctors, that fear is compounded by frightful images of the dismembering nature of the practice. All physicians perform a prolonged autopsy during their freshman medical school anatomy class and most attend at least one more during their training. We know the reality – it is a barbaric anachronism lacking any real medical value.

Since the advent of CT and MRI scanning, diagnostic ultrasound, flexible fiber-optic scopes, and angiography of all sorts, there isn’t a body cavity, tissue, or vessel that can’t be imaged or sampled. Very few people die without a known cause  – and, even in the rare instances when that does happen, why should a postmortem examination be needed? It is dirty, malodorous, and dangerous. It carries infection risks for pathologists. It is not reimbursed by private insurance, Medicare, or Medicaid. Where is the upside for pathologists?

Those rare physicians who want to perform autopsies can undertake a forensics fellowship – but, again, why must they be pathologists? If there are surgeons, radiologists, or genetic counselors with an interest in autopsy science, let them be the forensic physicians and leave the pathologists be.

The prospect of performing autopsies nearly drove me away from a pathology residency (and did result in the loss of one of my seven fellow residents). After two years, I left my pathology residency to undertake a rotating clinical internship, hoping to defeat the negative stereotypes – but the misconceptions continued. And that was when it became clear to me that the single greatest reason our classmates and colleagues do not fully accept us is the autopsy. Its time has passed. It is time for it to go. An additional medical school rotation in pathology and laboratory medicine – even just two weeks each – and a required clinical internship would help. But by far the greatest impact would be to eliminate autopsy pathology from residency training. The time gained could be spent on surgical pathology to the betterment of the program and its residents.

In summary, it seems to me that pathology recruiting would be greatly assisted by three relatively simple changes: i) mandatory pathology and laboratory medicine rotations in medical school; ii) a required clinical internship for pathology residents; and iii) elimination of autopsy practice from pathology residency. The time has come for these bold steps.