From the day I started medical school in Yugoslavia (now the Republic of Serbia), diseases fascinated me – from their clinical characteristics to the symptoms they cause in a person’s body. Eventually, this fascination drew me to pathology. I always had a special interest in how cancers, inflammation, and other processes appeared in the body. I’m a visual person, so I remember the first time I saw a heart with myocardial infarct and thrombus in the corresponding vessel – it was the best learning experience I could have had on the pathology of myocardial infarction. Every field of medicine features a range of diseases and disorders, but forensics called my name because each case was so different. As medical examiners, we may see rare genetic disorders and the worst possible crimes all in the same day – which makes the job both interesting and challenging.
Currently, I am the senior medical examiner at the New York Office of the Chief Medical Examiner. My main responsibilities involve investigating people’s causes of death – examining bodies; performing autopsies; undertaking additional testing such as toxicology, microbiology, molecular, and histology sampling; reviewing medical records; and working with law enforcement and medicolegal investigators to get pertinent information. I also supervise doctors in forensic training – teaching while performing autopsies and lecturing in pathology – and testify in court as an expert witness.
My job is never boring and constantly reinforces my natural curiosity. On a typical day, we have an early meeting to triage cases that must be examined that day, which gives each medical examiner several cases to handle. Based on the nature of the case – natural or unnatural death – medical examiners can perform additional procedures, such as full body scans, DNA or evidence collection, detailed photographs, and more. After the body is positively identified and the exam (including the autopsy and reviewing all medical and investigative materials) has been completed, the medical examiner issues a death certificate with a cause-of-death statement. Many days also involve time in my office reviewing additional tests, finalizing autopsy reports and death certificates, or communicating with families – but, of course, these are just some of a medical examiner’s many tasks.
Credit: Jole Lupo.
Hidden value
The value of autopsy can often be overlooked in pathology training – but I strongly believe it is crucial for the education of every pathologist, regardless of subspecialty. In fact, every medical student should at least see an autopsy procedure; they don’t have to love it or do it, but I guarantee they will learn from it. I often get positive feedback from medical students when they’re observing an autopsy, particularly when they realize what “normal lungs look and feel like” or how diseases actually look in the body. In fact, one of my favorite pieces of feedback was a medical student who thanked me for teaching them how to orient a heart – and they were going into cardiology! It shows that many medical students have never seen normal or diseased examples of the organs they will eventually treat. A student interested in vascular surgery even told me once that there was no book or video to show the appearance of markedly calcified atherosclerosis, so it had remained a mystery until that day.
This is a problem no matter where medical students are in their education journeys. For example, when I asked a fourth-year medical student going into internal medicine what he was looking at during an autopsy, he identified the liver – but not its marked steatosis and cirrhosis. As a doctor, you should be able to not only recognize the organs of the body, but also distinguish between normal and diseased states. As a pathologist, the ability to recognize gross pathology (rather than just microscopic abnormalities) is a must because, if you want to become an excellent pathologist, you don’t skip steps – you start from the very beginning with autopsy and gross pathology.
Though there is value in autopsy and we as pathologists can learn a lot about our deceased patients, it is not necessary in every case, especially if a death is expected due to the severity of natural disease. In these cases, the value lies in the learning experience and in confirming the extent of the disease – perhaps even a discovery of incidental findings or undiagnosed complications.
In cases of unexpected natural deaths, or unnatural, violent, or pediatric deaths, autopsy can be a crucial tool. For example, you might discover a rare genetic mutation that causes cardiac dysrhythmia, which then leads to the person’s family seeking genetic counseling. You might detect pathogens that pose a potential threat to public health (for example, cases of undiagnosed meningococcal meningitis) or determine whether the cause of death in a person with a positive SARS-CoV-2 PCR test was COVID-19 or something else. You might learn valuable information – for instance, we learned much of what we know about COVID-19 from autopsies, and it has enabled us to strengthen medical care for living patients. Most of all, you bring closure to families.
Through the veil
Autopsy is a surgical procedure composed of somewhat disturbing visual details, unpleasant smells, and large cutting tools. It’s rare to find a doctor who will say, “I love autopsy.” Even trained medical examiners are not always excited by a severely decomposed body with a strong odor. The truth is, there is nothing beautiful about autopsy – but if you look past those first impressions to the medical case itself, the task becomes interesting. I have many students who changed their initial negative opinions after we discussed their feelings on seeing an autopsy being performed.
We live in an era of new technologies. Many doctors may believe that you can just scan a body to find out how the person died. Though I don’t completely disagree with this statement (in many cases, we can scan for significant pathology, such as fractures or subdural hematomas), you can only diagnose so much via postmortem imaging. For example, a heart with undiagnosed myocarditis might look completely normal on imaging, but an autopsy reveals the condition. Personally, I believe that when doctors talk negatively about autopsy, the mindset passes down to the new generation of doctors and the cycle begins again.
Credit: Jole Lupo.
A new approach
Our approach to autopsy in medical education must change if we are to counteract students’ negative perceptions. Every medical student should be encouraged to see and be curious about a postmortem body and to delve into the anatomy and pathology behind it. Pathologists should encourage residents to do the same or even take a step further by training them to perform autopsies. When I was a medical student, the school presented autopsy as a critical and educationally valuable skill. I remember seeing my first body – after a minute of shock, I was deep into the chest cavity, fascinated by the metastatic cancer. Not everyone will feel the same, of course, but it’s important to understand that seeing the procedure firsthand is the best way to learn.
To those who find autopsy off-putting or unnecessary: try to overcome your anxieties and misconceptions, pay attention to the case, and look beyond the graphic sights (and smells). Everyone who comes into the autopsy room with a positive perspective will be surprised at how much pathology they learn. To pathologists and medical educators who believe autopsy should be removed from the training curriculum, I say: try to overcome your negativity toward autopsy – perhaps even observe one if you haven’t yet. Otherwise, negative opinions about autopsy will continue to haunt new generations. In the words of Charles Hirsch, the late Chief Medical Examiner of New York City, “Nothing can equal the thoughtful medicolegal autopsy as a teacher of the amazing variability of human responses to disease and injury.”
Credit: Jole Lupo.
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