Reviving the autopsy as a valuable training tool
From the July-August ACP Observer, copyright © 2005 by the American College of Physicians.
By Yasmine Iqbal
When Jehan El-Bayoumi, FACP, was a third-year resident, she learned one of the most valuable lessons of her training from a patient who had already died.
According to exams, labs and imaging tests, the elderly man had expired from congestive heart failure. But an autopsy told a much different story: The patient was suffering from advanced lung cancer with lymphangitic spread, a condition that can mimic congestive heart failure. Not one of the sophisticated tests he had received, however, picked up the difference.
That experience cemented the importance of the autopsy in Dr. El-Bayoumi's mind. "We were all so confident about our diagnosis," she recalled, "but we were wrong." While the patient would have died no matter what treatment was administered, only the autopsy had the power to reveal the true cause of death.
"It's a very humbling experience to realize that technology isn't always right."
—Jehan El-Bayoumi, FACP
"We tend to think that CT scans and other imaging techniques are 100% accurate, but they're not," said Dr. El-Bayoumi, who is now the internal medicine residency program director at George Washington University School of Medicine in Washington. "It's a very humbling experience to realize that technology isn't always right."
Today, Dr. El-Bayoumi is a strong proponent of the autopsy, and not just as an investigative tool to determine the causes of death and to improve quality control. She also views it as an important teaching tool to help residents learn about the pathophysiology of disease and understand the limits of clinical tests and exams.
At many hospitals, however, these teaching opportunities are becoming increasingly rare. According to a 2001 report from the Centers for Disease Control and Prevention, fewer than 10% of all deaths in the United States resulted in an autopsy in the mid-1990s. In 1961, by comparison, autopsies were performed on 41% of patients who died.
While the report cites regulatory, economic and cultural reasons for that declining popularity, an even more likely explanation is that many physicians no longer believe that the autopsy has value.
Senior resident Sonja Wyche, MD, (left) discusses a spin X-ray with Wassim M. Mchayleh, ACP Associate, during an autopsy conference at George Washington University.
"Clinicians and even some pathologists don't feel like they're going to get anything out of an autopsy," said Tim Jennings, MD, director of the pathology lab at Albany Medical College in Albany, N.Y. "They'd rather concentrate on the living. Once the patient dies, they think their job is over."
Hospitals are trying to get more mileage out of the autopsies they do perform by developing conferences to discuss autopsy results and encouraging residents to review autopsy reports. Just as importantly, hospitals are also trying to boost the number of autopsies being performed by giving residents the skills they need to initiate what can be a difficult conversation with grieving family members. (Also see, "How hospitals are trying to boost the number of autopsies being performed.")
At George Washington University, where 10% of deaths are autopsied, multidisciplinary teams review one or two notable cases in a bimonthly conference.
"The best conferences occur when all the doctors who have had contact with the patient are involved," said chief resident Neeral L. Shah, ACP Associate. "The residents who treated the patient discuss what they were thinking at each point during the patient's care, radiology residents review the patient's films, and pathology residents present the gross pathology and tissue specimens."
Correlating these different elements, Dr. Shah explained, provides a comprehensive and invaluable picture of what transpired. Seeing the gross pathology, he added, is always one of the most illuminating parts of the conference. "It's one thing to see what a lung with pneumonia looks like on an X-ray," he said, "and another to see the actual lung."
Other residents agree that seeing disease evidence in an actual organ—lungs with ARDS or a liver with severe cirrhosis—can go a long way in helping them understand a disease. "When you're able to feel something like a liver metastases, how hard and firm that is, it stands out in your mind and helps you to gain and retain knowledge of that particular diagnosis," said Lucas D. Shippee, ACP Associate, a third-year resident at Albany Medical College.
At Albany, monthly autopsy conferences also teach important lessons about the limits of medical tests and technology. One recent autopsy, for example, revealed an unusually placed duodenal ulcer that two endoscopies had missed. Another autopsy uncovered significant erosion in the stomach and esophagus of a patient with a nasogastric tube.
"In that case, everything was done correctly, and the patient had been on gastric protection," said Neesha Naik, MD, a third-year resident at Albany. "But it taught me that nothing we do is ever really benign, and sometimes we can't prevent adverse outcomes. It also made me realize how important gastric protection is."
Alwin F. Steinmann, FACP, Albany's internal medicine residency program director, noted that the conferences also provide a sense of closure for the participants. "We treat patients based on clinical exams and laboratory findings, so it's important to connect those with the pathology findings," he said. "It's kind of like taking a test and finding out what the real answers are."
Approaching the topic of autopsy with a family in the first throes of grief can be difficult. While some families will request an autopsy, most haven't thought about one and probably don't want to talk about it. Particularly in those instances where the patient has died after a protracted illness, many family members may just want to let the body rest in peace.
But experts say the key to getting a family to agree to an autopsy might be in how you ask. That's why some hospitals are giving residents training to get them to be more comfortable making that request.
At George Washington University, for example, the pathology department conducts regular seminars on this topic. Albany Medical College brings up the topic of autopsies at M&M conferences, and educators encourage first- and second-year residents to call on senior residents for help in requesting autopsies. And at Boston's Beth Israel Deaconess Medical Center, educators talk about autopsies during orientation week and have developed an autopsy request sheet.
Experts say that if the subject is approached with sensitivity and conviction, even reluctant families can be persuaded. Here's what they advise:
Give the family time to grieve. Joseph A. Hardman, ACP Associate, a third-year resident at Beth Israel Deaconess, said that timing can be everything. "After telling a family that their loved one has passed," he said, "I give them time to absorb the news before bringing up an autopsy."
Explain the benefits. Most families will want to know why you're asking for an autopsy. Diane L. Levine, FACP, executive director of medical education at Wayne State University School of Medicine in Detroit, suggested saying something like, "I know this is a difficult subject to bring up, but we would like to do an autopsy to better understand why your family member died and how to provide the best care for future patients." You can also explain that an autopsy might reveal medical conditions that could help families better understand and safeguard their own health.
Address concerns. Families are often concerned about what the body will look like afterwards; this can be a special concern for families planning an open casket funeral service.
If you can assure families that an autopsy is not incompatible with an open casket—all organs can be replaced, for example, and the funeral won't be delayed—you can alleviate some of their biggest fears.
Present options. Some families are reluctant to have certain sensitive areas autopsied, such as the head or the genitals. Although a full autopsy is preferable, let families know that other options such as a limited autopsy or even a postmortem biopsy are available.
Consider "gentler" terminology. Dr. Hardman pointed out that the word "autopsy" can conjure up all sorts of ghoulish images. Instead, he asks family members for permission to conduct a "postmortem examination."
"It's a gentler way of requesting an autopsy," he said. "It helps families realize that this is just an extension of the care we provided while the patient was alive."
Don't be intimidated by the threat of a lawsuit. "There's a latent fear that an autopsy might uncover something that was missed," said Albany Medical's Dr. Jennings, "and that this could lead to a lawsuit. But in the vast majority of cases, he said, the evidence is protective and supports the argument that quality care was administered."
"When you offer an autopsy, you're demonstrating that you have nothing to hide—you just want to find answers," Dr. Hardman added. "So many studies have shown that this kind of openness and honesty actually results in less litigiousness."
Finally, the key to getting consent is to help family members realize that an autopsy is part of good medical care. "Our care of the patient doesn't end when the patient dies," said Dr. El-Bayoumi. "Aftercare for the family, which includes an autopsy, helps us honor our patients."
Yasmine Iqbal is a Philadelphia-area freelance writer specializing in health care.
Autopsies may provide valuable educational opportunities for residents, but only if enough patients and their families consent to the procedure. As a result, hospitals are finding new ways to stress the importance of autopsies to residents in an effort to increase the number of autopsies they perform.
Wayne State University School of Medicine in Detroit, for example, has implemented several measures to help residents learn from autopsies—and to help them become more comfortable in requesting them.
The monthly autopsy case conferences are the hospital's best-attended meetings and usually draw about 60 participants. Discussions focus on the clinical and pathology findings of one or two interesting cases.
Earlier this year, Swati Pawa, MD, chief internal medicine resident at Wayne State, began a comprehensive autopsy orientation program. She speaks regularly to residents about the value of autopsies and makes sure they are familiar with the autopsy request forms.
Dr. Pawa also brings up the topic during daily morning conferences when discussing the condition of terminal patients. Her goal is to remind residents that the time to ask for an autopsy might be imminent.
And every time a patient dies, Dr. Pawa follows up with residents and asks if an autopsy consent was obtained, and if not, why. Every month, residents are asked to fill out a survey on their reactions toward autopsy and their experiences in obtaining consents.
Dr. Pawa is currently conducting a study to determine if these interventions make any difference in autopsy rates. Initial surveys show a low awareness of autopsy and many misconceptions, but those are gradually changing.
"The case conferences have helped teach the value of autopsies," she said. "The interventions have helped residents become much more comfortable asking for them."
While residents learn from witnessing an autopsy, simply reading an autopsy report can also provide valuable insights. That's why some hospitals have developed systems to get these reports back to the residents involved in the patient's care.
At Boston's Beth Israel Deaconess Medical Center, for example, the pathology department e-mails a copy of each autopsy report to every physician on the care team. Although the hospital doesn't hold regular conferences, the pathology department does send out weekly e-mails that announce which autopsies will be performed and invite residents to attend.
And at Albany Medical College in Albany, N.Y., residents can view autopsy reports on intranet databases. The pathology department also speaks with residents before performing an autopsy, and sends housestaff the results.
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