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 hadn’t 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 she’d 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 all—but 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 patient’s 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 autopsies—while obviously available too late to benefit those patients—may 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, Latham—like many pathologists—fears the rising notion that the “autopsy has died a natural death.”

Forty-five years ago, nearly 50 percent of the patients who died in teaching hospitals—like GW Hospital—were 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 teachers—skilled hands that got dirty, that didn’t 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 percent—just under 50 autopsies per year at GW. At many community hospitals it’s between zero and five percent.

With increasingly powerful and accurate technology at their fingertips, doctors are investing more faith in their diagnoses and don’t feel the need to have an autopsy done, says Latham. But she believes strongly that it’s a practice that we can’t 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 autopsy’s downward spiral can be traced back to one thing, says Latham—a 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 effect—one link in the chain knocking into another, and then another, until all the pieces have fallen.

As a culture, we don’t 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 it’s a dead body,” says Woodruff. “And of course what they’re really saying is ‘I don’t want to hurt anymore, emotionally.’”

For some, this suggests that people don’t know much about the autopsy because they don’t want to know. But what people should know about autopsy could fill an article. Many people, for instance, don’t know that the autopsy is free (yes—literally free) if the patient dies in the hospital. They also aren’t 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 aren’t told that the autopsy can be a way of uncovering possible unknown medical conditions of the patient that may be genetic or hereditary—such as breast cancer or heart disease—that 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.

Without doctors armed with knowledge to disable the stigma—by educating the public on the procedure and its benefits—the stigma only continues to spread, knocking down other dominos in its path.

And then there’s money. While GW’s approximately 50 autopsies per year barely makes a dent in the hospital’s 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 hospitals—in the form of health statistics, court evidence, and quality control at hospitals. Nevertheless, many of these organizations are unwilling to accept any financial responsibility.

“Let’s start with the premise of health care—it’s health care. A dead person doesn’t need health care,” says Greg Gesterling, assistant director of legal and regulatory affairs for the George Washington University Health Plan. Just as his company doesn’t cover funeral costs, neither does it cover autopsies. “It’s not health care,” he says, “it’s something else.”

“I think many groups support the autopsy in the generic—in 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 haven’t had to pay for in the past, and [something] that is going to have a benefit that is diffuse—a benefit to society, a benefit to science—but 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 patients—the ones who die.”

If the practice really is only in a coma, Latham is doing all she can to wake it up. There’s a certain emphasis on a getting-them-while-they’re-young mentality in her approach—she knows that if medical students don’t 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 hospital’s autopsy suite along with pathology faculty and some physicians. A pathology resident reviews the patient’s 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 we’ve 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 Center’s Department of Medicine. “So we try to make people understand that it’s difficult, that we’ve all been there, the importance of it, and try to make them feel as secure and comfortable as possible. But it’s an on-going learning experience.”

Latham recently helped fight—and win—a 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 patient’s 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 there’s little—if any—enforcement 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,’ that’s all it would take.”

While Wasserman agrees on the importance of the autopsy form, “the problem here is that we’re talking about a very sensitive issue and time,” he says. “It’s an emotionally difficult and draining situation not only for the family, but for the physician as well. We’re not talking about something that’s 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 don’t think we’ll ever lose it completely,” Wasserman says, optimistic about the future of the autopsy. “It’s 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 we’ve learned enough to save lives, that this will never die out.”

Holding up a dark slice of lung that’s scaly like a chunk of charred wood, Latham is showing the half a dozen students before her a piece of pathological evidence. “You’re not going to get this black as just a city-dweller—this 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 patient’s 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 with—and enlightened—science 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 Alexandria—reportedly 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 weren’t enough—as they often were not for the needs of medical schools even up until the 20th century—grave 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 souls—in a line dividing their conjoined livers—and 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. Rembrandt’s 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 man’s 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 Alzheimer’s 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 Legionnaire’s 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.
—DF