In the age of MRIs, CT scans, and HMOs, the number of autopsies performed in hospitals continues to plummet, and many pathologists fear the autopsy may be dead. Some GW faculty members are trying to restart this heart of medical science. By Danny Freedman
It had been eight years since doctors removed a lump from her breast and eight years without a recurrence. With a battle against cancer under her belt, it took five days of flu-like symptoms, including two days of shortness of breath, to drag this 50-year-old survivor back to the hospital.
She hadnt planned to stay in the hospital overnight. Doctors in the emergency room at GW Hospital wanted to have her admitted though, so they could check out a possible viral infection. She had to go home to feed her pets and plants, but promised that shed come back, and the doctors let her go.
The woman drove back to the hospital three hours later and was admitted that evening. The next morning she was dead.
An autopsy revealed that she had not been suffering from a viral infection at allbut from a recurrence of breast cancer. Not until the postmortem examination and the subsequent microscopic study of her organs did pathologists discover a layer of cancer cells sprinkled over her lungs and heart. The spread of cancer cells had never formed a tumor large enough to be detected by her physicians.
It was quite a surprise for the physicians taking care of her, says Dr. Patricia Latham. As chief of autopsy services at the GW Hospital, she points to this patients story as a classic example of the importance of the autopsy.
A recent study showed that nearly 20 percent of the patients autopsied in a Cleveland hospital had differing diagnoses in life and in death. Published in the February 2001 issue of CHEST, the journal of the American College of Chest Physicians, the study found a 44 percent incidence of major pathology at autopsy that had not been diagnosed in life. The information gained from these autopsieswhile obviously available too late to benefit those patientsmay be the difference between life and death for future generations with similar symptoms.
Latham laments that, even with studies such as this, the relevance of the autopsy is still being questioned. In an age of MRIs, CT scans, and a tremendous faith in the work of technology, Lathamlike many pathologistsfears the rising notion that the autopsy has died a natural death.
As a culture, we dont like to disturb the dead. We tiptoe through graveyards. We whisper in funeral homes. We are taught early on to just let them be.
Forty-five years ago, nearly 50 percent of the patients who died in teaching hospitalslike GW Hospitalwere being autopsied. It was a procedure held in high regard by doctors who believed in its strength. They had been carefully trained in medicine by learning at the hands of their teachersskilled hands that got dirty, that didnt have buttons to push on high-tech machines.
But old medical techniques grayed and moved to big houses in Boca. By 1985, hospital autopsy rates had dropped to 14 percent, according to a 1997 summary report of past research by the Institute of Medicine of Chicago. Technology had grown, and managed care checked into the hospitals. The Joint Committee on the Accreditation of Health Care Organizations, which had a minimum autopsy requirement for accredited hospitals to maintain, sawed down the number from 25 percent to 15 percent in the mid-1990s, and has since dropped the requirement altogether.
The nationwide picture continued bleak in a 1994 survey of hospitals conducted by the College of American Pathologists, which showed that 75 percent of hospitals had autopsy rates below 13.5 percent and that half of those had autopsy rates at or below 8.5 percent.
In 1995, the National Center for Health Statistics stopped reporting autopsy rate data. And today the autopsy rate at GW, as at many teaching hospitals, hangs slightly below 15 percentjust under 50 autopsies per year at GW. At many community hospitals its between zero and five percent.
With increasingly powerful and accurate technology at their fingertips, doctors are investing more faith in their diagnoses and dont feel the need to have an autopsy done, says Latham. But she believes strongly that its a practice that we cant afford to lose.
With the number of autopsies dwindling, fewer interns and residents are exposed to the practice. These doctors-in-training have fewer confrontations with the issue of autopsy and hence feel uncomfortable broaching the subject with grieving families of deceased patients.
The autopsys downward spiral can be traced back to one thing, says Lathama lack of good information. Little direct exposure to the autopsy among doctors contributes to misinformation among patients and patients families. This general lack of knowledge about the autopsy among the public fuels the very stigma that is suffocating the procedure, both socially and financially. The string of misinformation is like a domino effectone link in the chain knocking into another, and then another, until all the pieces have fallen.
As a culture, we dont like to disturb the dead, says Pamela Woodruff, who teaches a psychology course at GW called Attitudes Toward Death and Dying. We tiptoe through graveyards. We whisper in funeral homes. We are taught early on to just let them be.
This distancing, of course, includes postmortem procedures like the autopsy. I think a lot of people feel that somehow pain is involved, even though its a dead body, says Woodruff. And of course what theyre really saying is I dont want to hurt anymore, emotionally.
For some, this suggests that people dont know much about the autopsy because they dont want to know. But what people should know about autopsy could fill an article. Many people, for instance, dont know that the autopsy is free (yesliterally free) if the patient dies in the hospital. They also arent aware that there can still be an open-casket funeral after an autopsy, and that families can request limitations on the scope of the autopsy. Most people arent told that the autopsy can be a way of uncovering possible unknown medical conditions of the patient that may be genetic or hereditarysuch as breast cancer or heart diseasethat might have implications for living family members. The autopsy also serves as a measure of quality control within the hospital, establishing a final diagnosis and assessing the treatment the patient received.
Most people arent told that the autopsy can be a way of uncovering possible unknown medical conditions of the patient that may be genetic or hereditarysuch as breast cancer or heart diseasethat might have implications for living family members.
Without doctors armed with knowledge to disable the stigmaby educating the public on the procedure and its benefitsthe stigma only continues to spread, knocking down other dominos in its path.
And then theres money. While GWs approximately 50 autopsies per year barely makes a dent in the hospitals budget, money is an issue for hospitals that conduct more autopsies. According to a 1995 survey of hospital pathologists by the Institute of Medicine of Chicago, lack of direct reimbursement for autopsies ranked the highest on a list of reasons for the decline in autopsy rates. At a cost to the hospital ranging from $1,500 to $3,000 per autopsy, Latham feels that sharing the cost with others that benefit from autopsy data could be a step toward picking up fallen dominos.
For example, information gathered from autopsies benefits insurance companies, law firms, HMOs, and hospitalsin the form of health statistics, court evidence, and quality control at hospitals. Nevertheless, many of these organizations are unwilling to accept any financial responsibility.
Lets start with the premise of health careits health care. A dead person doesnt need health care, says Greg Gesterling, assistant director of legal and regulatory affairs for the George Washington University Health Plan. Just as his company doesnt cover funeral costs, neither does it cover autopsies. Its not health care, he says, its something else.
I think many groups support the autopsy in the genericin the non-specific, says Latham, but when it comes down to who will pay for it
no one wants to pay for something that they havent had to pay for in the past, and [something] that is going to have a benefit that is diffusea benefit to society, a benefit to sciencebut not necessarily a benefit to their pocketbook or to any given individual.
The autopsy is not dead, but it slumbers deeply, apparently the victim of a vast cultural delusion of denial, wrote George D. Lundberg, MD, in 1998 as editor of the Journal of the American Medical Association. It is not exactly a conspiracy of silence or necessarily a massive intentional cover-up, but it is a movement with millions of players, all in complicity for widely varying reasons with the final result of do not bother me with the truth on the sickest patientsthe ones who die.
If the practice really is only in a coma, Latham is doing all she can to wake it up. Theres a certain emphasis on a getting-them-while-theyre-young mentality in her approachshe knows that if medical students dont learn the importance of the autopsy now, they may never get another chance.
Second-year medical students in her pathology lecture are encouraged to attend weekly autopsy conferences in the hospitals autopsy suite along with pathology faculty and some physicians. A pathology resident reviews the patients medical history and the autopsy findings, and Latham quizzes the half-dozen medical students, who stand around a gurney in latex gloves, examining the organs lying before them for a cause of death.
Autopsy-related issues are discussed at daily meetings and regularly-held conferences. All medical house staff and residents are required to attend, and ideally, the forced mixing of the departments of radiology, medicine, and pathology in discussing autopsy cases allows for a greater understanding between the departments.
We have to make sure the house staff and residents realize the difficulty and that weve all been there as physicians being in that position of asking for an autopsy, says Dr. Alan G. Wasserman, GW Professor and Chairman of GW Medical Centers Department of Medicine. So we try to make people understand that its difficult, that weve all been there, the importance of it, and try to make them feel as secure and comfortable as possible. But its an on-going learning experience.
Latham recently helped fightand wina battle to include autopsy forms in the death packets that doctors fill out whenever a patient dies. Because doctors are required to fill out every form in the packet before the hospital signs off on a patients death, Latham says this paperwork should ideally force one to consider the autopsy option, or at least list the reasons why they decided against requesting one.
The form, however, has had zero impact, Latham says. No one is filling it out, she says, and theres littleif anyenforcement of the policy.
The only way, in my opinion, that we can impact this situation is for someone in a position of authority to unequivocally support the form, says Latham. If they said, We will not accept the case as being complete until you do so, thats all it would take.
While Wasserman agrees on the importance of the autopsy form, the problem here is that were talking about a very sensitive issue and time, he says. Its an emotionally difficult and draining situation not only for the family, but for the physician as well. Were not talking about something thats like asking permission to get an X-ray. It is a difficult thing to do at the most difficult time for that family.
Often times, he says, if the family is approached the right way and told of the importance of the autopsy, the doctor will be successful in gaining consent.
I dont think well ever lose it completely, Wasserman says, optimistic about the future of the autopsy. Its too important a teaching tool. There are too many people who, like myself, have learned so much over the years by the use of autopsy, and really believe that weve learned enough to save lives, that this will never die out.
Holding up a dark slice of lung thats scaly like a chunk of charred wood, Latham is showing the half a dozen students before her a piece of pathological evidence. Youre not going to get this black as just a city-dwellerthis is smoking, she says. She tugs on the upper right side of the lung. She sees the cystic spaces and feels the familiar loss of substance in the tissue between her gloved fingers.
This is Emphysema, she says.
She moves over the patients organs laid out on the autopsy table, probing the autopsy resident about the case, while dishing out and fielding questions from the medical students attending the autopsy conference. She opens the heart along one of the postmortem incisions, showing the mitral valve. Students lean in for a closer look. A student asks, How did you know the valve thickening there was disease, and not just normal for his age?
Experience, Latham says.
Disease can have distinctive features, as you see here, she says, but often times it is simply a matter of experience. The more cases you can see, the more skilled you become. Never miss an opportunity to see things for yourself.
The writer gratefully acknowledges the help and guidance of Dr. Patricia Latham, chief of autopsy services at GW Hospital, in researching this article.
In the Beginning
Named for the Greek word autopsia, meaning seeing for oneself, the autopsy as we know it evolved withand enlightenedscience for more than 400 years prior to the birth of Christ, according to Dr. Kenneth V. Iserson, author of the 1994 book Death to Dust: What Happens to Dead Bodies?
Greek physicians practiced the first-recorded distant relative of the autopsy in the fifth century B.C., although it was described as an unpleasant, if not cruel, task. Egyptian physicians Herophilus and Erasistratus used the autopsy to teach anatomy and pathology between 350 and 200 B.C. in Alexandriareportedly by dissecting live criminals for their studies, examining even while [the patients] breathed, those parts which Nature had before concealed, according to Iserson. Used mainly for anatomical study at this point, the autopsy received a negative perception that was perpetuated by the use of criminal bodies. And when those werent enoughas they often were not for the needs of medical schools even up until the 20th centurygrave robbing became a medical students pastime.
Slowly, though, the practice of autopsy gained momentum as its usefulness in medicine and teaching became clearer. Autopsies on fallen foes were permitted among the doctors who followed the Roman army into battle. Pope Sixtus IV allowed medical students in Bologna and Padua to examine plague-ridden bodies in an attempt to determine the cause of the disease.
The autopsy reportedly came to the New World on July 19, 1533, in Santo Domingo on the island of Hispaniola, according to Iserson. The procedure was an attempt to determine if a set of recently deceased Siamese twins had one soul or two, so the priest would know how many postmortem baptisms to perform. Fortunately for the twins, the surgeon-dissector found evidence for two soulsin a line dividing their conjoined liversand two baptisms were performed. Unfortunately for the priest, the twins father refused to pay for two baptisms, and Iserson writes, as far as he was concerned, a single soul was enough.
In the 1600s an autopsy was used in the American Colonies to determine if an 8-year-old girl had died of witchcraft. Rembrandts painting The Anatomy Lesson of Dr. Joan Deyman captured the 1656 autopsy of a 28-year-old man hanged for criminal acts. Physicians are believed to have focused on the mans brain in an attempt to find reasons for his criminal behavior, Iserson writes.
The first comprehensive pathology text was published in 1769, written by Italian physician Giovanni Batista Morgagni. It is credited with correlating autopsy findings with clinical disease, giving rise to the practice of anatomic pathology. Pathologists studying tissues and cells in the mid-1800s brought about the dawn of microbiology.
The germ theory of disease, developed in the 1870s, was built in part on Hungarian obstetrician Ignaz Philipp Semmelweis autopsy research from 30 years earlier. Despite his unpopularity in insisting that doctors wash their hands with soap after leaving the autopsy room to see patients, the germ theory led to the isolation of diseases including anthrax, diphtheria, tuberculosis, leprosy, and the bubonic plague.
German neurologist Alois Alzheimer performed an autopsy in 1906 on a 54-year-old woman with a history of increasing confusion and memory loss. He was the first to notice the disorganization of the nerve cells in her cerebral cortex. And even today, it has been said that the only way to definitively diagnosis Alzheimers disease is through autopsy.
Autopsies have revealed the causes of heart attacks and angina pectoris (chest pains, often from decreased oxygen to the heart), appendicitis, and the effects of irradiation; they have provided the pathological definition of acquired immunodeficiency syndrome (AIDS), linked cigarettes to lung cancer, and charted the spread of various cancers. They have marked the causes of Legionnaires disease, toxic shock syndrome, and a new strain of the Hantavirus, and have brought to light some of the risk factors leading to sudden infant death syndrome (SIDS).
Discoveries made by peering into the depths of the human body have transformed the world. As this abbreviated chronicle indicates, without the autopsy much of medical science would have remained merely guesswork.