To the Editor.—
As academic autopsy pathologists, we read with dismay the editorial entitled “A New Kind of Autopsy for 21st Century Medicine” in the July 2017 issue of the Archives of Pathology & Laboratory Medicine.1 Based on the criticisms of the autopsy process, it appears the author is not familiar with the autopsy service in a teaching hospital. We feel that such a lack of understanding (unfortunately, not uncommon among physicians) contributes to the already declining autopsy rate and does a disservice to our clinicians, students, patients, and their families. Before we address specific concerns about the editorial, we would like to review the purpose of a hospital autopsy.
Perhaps the most important objective of a postmortem examination is to discover why a patient died, providing closure to both the deceased's family and the clinical team who cared for the patient. Family members have thanked our service, and we frequently receive acknowledgement from our clinical colleagues for assisting in complex cases that are discussed at departmental morbidity and mortality conferences.
Quality assurance is another important function of the autopsy. Some will question the necessity of the autopsy given the plethora of information provided by the deceased's laboratory studies, imaging, and clinical examinations. However, even in the current technologically advanced era, autopsies have been shown to disclose diagnostic errors in nearly 30% of cases.2,3 Even if the postmortem findings are not different from the clinical impression, they still may have important implications for the health of family members.
Yet another role of the postmortem examination is education. An autopsy gives medical students and residents the unparalleled experience of viewing anatomy and gross pathology firsthand. In several recent examples, experience in our autopsy service has inspired medical students to pursue pathology as a specialty.
In his editorial, Dr Laposata bemoans the shortcomings of the autopsy, which he claims does not address specific clinical questions, and argues that subspecialists should perform autopsies.1 We have a different opinion.
Clinical-pathologic correlation is key in all hospital autopsies, and we consider it our duty to identify any discrepancies between diagnoses before and after death. Because of that, the clinical impression, laboratory findings, and radiologic studies are always reviewed and considered before the prosection. A discussion with the clinical team before commencing the postmortem examination ensures that all questions are addressed, and appropriate specimens for ancillary tests are collected.
A good autopsy pathologist needs to be an excellent general pathologist. In fact, all of our autopsy service faculty are board certified in both anatomic and clinical pathology. Postmortem examinations require skills that bridge anatomic and clinical pathology because they involve examination of all organ systems and interpretation of laboratory data before and after death. If an autopsy is performed only by a subspecialist, that autopsy will focus predominantly on the pathology of interest to that subspecialist. Other pertinent findings may not be recognized. For example, a pulmonary pathologist who performs autopsies only when there is a history of interstitial lung disease may lack the experience necessary to differentiate acute tubular necrosis from extensive autolysis or to appropriately contextualize the lung findings in the final report.
Although the proposed “diagnostic and management autopsy,”1(p887) in some situations, may help answer specific questions from the families or clinicians, it could be disastrous to the role of autopsy as a quality-assurance measure. By focusing an autopsy only on the assumed cause of death, as implicated by clinical and radiologic evidence, there is a risk of missing the true cause of death or other relevant findings. In other words—if you don't look for it, you won't find it.
Offering genetic testing as a surrogate to a complete autopsy is, at best, an expensive waste of resources and, at worst, harmful. Identifying a genetic mutation postmortem does not necessarily mean that it caused or even contributed to death. For example, although the CYP2C19 gene mutation mentioned1(p887) has been well characterized, the pathogenicity and penetrance of many other mutations are less understood. This issue is becoming more relevant as whole genome sequencing gains popularity. If a genetic variant of uncertain significance is identified without anatomic findings to confirm pathogenicity, the appropriate follow-up care becomes problematic. It is only in the proper anatomic context, with the appropriate clinical and family history, that the significance of such mutations can be interpreted.4
We are particularly disappointed by what we perceive as the author's acceptance of the general public's negative opinion of the autopsy (“His wife was pleased to avoid an autopsy”).1(p887) Offering a less-comprehensive exam as a substitute just perpetuates the incorrect notion that full autopsies are unnecessary. Attempts should be made to educate the public that the autopsy is a scientific, respectful procedure and that only a complete autopsy will provide complete answers. If our colleagues in pathology fail to advocate for us, we can surely expect further decreases in autopsy rates. The best way to maintain the quality of the autopsy is to continue training the next generation of qualified, dedicated autopsy pathologists. Autopsy rates could be improved by reimbursement from insurance companies or hospitals to ensure that financial burden to the family is not an obstacle. It is only by investing in our future that we can be sure the academic autopsy will continue to be relevant to clinical care, quality assurance, and medical education.
Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington.
Accepted for publication August 29, 2017.
The authors have no relevant financial interest in the products or companies described in this article.