On Investigating Death

Most people in North America die of natural causes – cardiovascular disease, cancer, or complications of diabetes to name just a few. The timing of these deaths is usually unsurprising and often doesn’t warrant further investigation. But in instances of accident, homicide, and suicide – or when a natural cause cannot be easily determined – the circumstances surrounding the death warrant expert opinion. The investigation of an unexpected death in hospital or following a surgical procedure can provide clinicians and surgeons with important quality control feedback. This information is important to families, the justice system, public health, and for future healthcare planning.

Although the Canadian population is approximately 10 percent of the US population, many of the challenges surrounding death investigation are similar in both countries. As a current pathology trainee with an interest in forensic pathology, I often wonder what these challenges mean for the future.

Death investigation in North America is the responsibility of each state and follows either the coroner system, the medical examiner system, or a hybrid of the two. Simply put, not all cause-of-death determinations require an autopsy and, although pathologists are the ones to perform the autopsy when required, whether or not they certify the final manner of death varies by region.

Autopsies fall into two general categories: forensic (medicolegal) and hospital (medical). Forensic autopsies fall under the jurisdiction of the local governmental death investigation system (coroner or medical examiner), whereas hospital autopsies are performed with consent of the deceased’s family in an attempt to answer specific questions regarding disease extent, effectiveness of therapy, or for hospital quality assurance.

Over the last few decades, autopsies have become less common in North America. Approximately 6 percent of all deaths in Canada lead to autopsy – a number that was closer to 13 percent in the early 1990s. The advent of advanced imaging techniques and the medical system’s increased ability to capture underlying disease early means that more deaths occur as a result of known complications of well-documented medical conditions. Because our understanding of normal disease timelines has improved, the decline in overall autopsy numbers is unlikely a major issue.

Prioritizing the diagnosis and treatment of living patients is a great thing – but the overall decrease in autopsy numbers, along with limited funding for death investigation in some regions, may create a catch-22 scenario for future workforce planning. Residents training to become pathologists are doing fewer autopsies than their predecessors and may therefore eventually be practicing with a diminished level of comfort in autopsy pathology. Could this have implications for death investigation capacity in the future? 

In Canada, pathology residency spans five years and often includes further subspecialty fellowship training. Over the last decade, science has made great strides in cancer biology and we have seen greater focus on personalized medicine; residents have more to learn about the routine cancer subtypes that encompass the majority of a typical pathologist’s workload.

Canadian pathology training programs often look to the US as a benchmark and guide to structure training. After all, it is not uncommon for Canadian graduates to complete fellowships or seek job opportunities in the US. In 2019, the Association of Pathology Chairs looked at the issue of autopsy education in the US in the context of declining numbers and competing educational demands (1). They concluded that autopsy training should remain an essential part of US pathology education, but that two residents could share the responsibility of an autopsy and have it count toward the 50-autopsy requirement (which was closer to 100 a few decades ago) for both of them. In the wake of the COVID-19 pandemic, the American Board of Pathology further decreased this requirement to 30 to allow residents to graduate on time. After all, for most grads, autopsies will form a very minor component of their careers.

As a trainee interested in autopsy and forensic pathology, I wanted to know how my colleagues felt about the role of autopsy in their education. Do they think it informs their general dissection and anatomy skills? Or is it useless if their end goal is to end up working in gastrointestinal or thoracic pathology?

In March 2020, just as the pandemic hit, I designed a national survey of Canadian pathology residents to learn more about what my resident colleagues thought (2). My goal was to quantify the number of autopsies Canadian residents aim to complete during training, understand their perception of access to and quality of autopsy skills education, and evaluate their interest in autopsy and forensic pathology as a future career. Across all Canadian institutions offering anatomical or general pathology programs, 26 percent of residents participated in the survey.

The results are in many ways reassuring – Canadian pathology residents do see value in the autopsy, with 83 percent of respondents rating autopsy education as either very important or important.  However, only 47 percent of participants agreed that all residents would easily be able to complete 50 autopsies during residency – and only 18 percent were interested in performing autopsies as a major part of their career. A combined 52 percent were only interested in performing autopsies to secure a desired position or felt having to do autopsies would be a job deterrent.

The quality of autopsy teaching and the number of autopsies performed were identified as the most significant factors affecting interest in performing autopsies as part of a future career. A combined 68 percent of respondents felt that the job market in forensic pathology in Canada was either good (better than most subspecialties) or very good (more jobs than graduating fellows). Of fifth-year residents in their final few months of residency, 71 percent reported having completed 50 or more autopsies. 

Given the ambitious national focus of this survey study, the results may be limited by self-selection bias and a relatively low response rate. Nonetheless, they lead me to think that general autopsy skills likely have a role in the future of pathology education. With younger physicians across all specialties having less exposure to autopsy, is there a benefit to bringing an abbreviated version of an “autopsy experience” into the general medical curriculum? I think so – and I urge my clinical colleagues to better familiarize themselves with the role, benefits, and limitations of the autopsy in modern medicine. As with any medical test, it’s important that we preserve scarce resources and choose wisely – but let’s not lose this important tool forever.