"Autopsy remains the touchstone of diagnosis," according to Henry Schneiderman, MD, of the University of Connecticut Health Center, Farmington (Schneiderman H, Gruhn J. J Postgrad Med. 1985; 77:153-6). But autopsy rates have declined precipitously in recent decades-from a peak of 41% in 1964 to less than 5% today (Hasson J, Schneiderman H. Arch Pathol Lab Med. 1995; 119:289-91). Schneiderman and colleague Jack Hasson, MD, label this situation a "disaster" because autopsy is an invaluable and irreplaceable tool not only for clinical medicine and epidemiology but also for medical education.
"Autopsies enable all physicians, both trainees and those who are more senior, to check the accuracy of their medical findings and the effects of their therapies," Schneiderman noted. "There is no test as powerful as this, even in the age of MRI and CT. There is a high rate of discovery of unexpected diagnosis at autopsy, particularly by trainees. It helps them to understand that our profession is not only not omnipotent, but not omniscient," he said. "It is also a potent reminder that patients are not immortal, so that one does not regard the decline and death of a patient as inevitably a medical failing, but as the nature of our species."
Eric H. Bernicker and colleagues at Baylor College of Medicine in Houston, Texas, evaluated the use of autopsies in an urban public teaching hospital during the AIDS era. Only 16% of patients who died in 1992 and 1993 had autopsies; however, significant, unsuspected diagnoses were found in 35% of the 152 patients who had an autopsy. Infections, pulmonary emboli, and myocardial infarction were the most common diagnoses, and HIV-infected patients had more unsuspected findings than did uninfected patients. The authors concluded that valuable, unanticipated information can frequently be obtained from autopsies in public hospitals (Bernicker EH, Atmar RL, Schaffner DL, Greenberg SB. Am J Med Sci. 1996; 311:215-20).
Reasons cited for the reluctance of physicians to order autopsies include the belief that technology has rendered them obsolete, pressure to cut costs, discomfort in approaching the family for autopsy permission, fear of litigation or professional discredit due to unexpected findings, inadequate compensation for pathologists, and inability to perform an autopsy properly. A recent addition to the list is increasing concern about infection control, particularly with the substantial number of patients who harbor HIV and drug-resistant tuberculosis organisms (Mitchell EK, Prior JT. J Community Health. 1995; 20:441-6).
Hasson and Schneiderman believe that better training of autopsy pathologists is one key to restoring the autopsy to its proper-and central-place in clinical medicine. Autopsy training programs, they note, must include intensive review of anatomy applied to dissection methods, direct supervision of less experienced autopsy pathologists by a senior pathologist, and review of all cases at gross organ conferences.
As a means of infection control, Erik K. Mitchell, MD, and John T. Prior, MD, of the State University of New York Health Sciences Center in Syracuse, propose the use of central off-hospital sites. "A community morgue meeting the strict standards of infection control would allow economy of scale from daily use with a full-time support staff trained in the protocol of infectious disease control," they write.
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