Quincy and his kind go the way of the dinosaur

Autopsy requests are on the decline, many say to the detriment of medical science. Trip to the morgue, anyone?

By Joshua Karpati

The number of autopsies performed in Canada has dropped precipitously in the past several decades. At 6%, the rate is now merely a tenth of its level in 1969. So why the decline? Unfortunately, there's no single definitive answer.

In the US, an equivalent drop is largely due to fear of malpractice suits and cost-cutting measures by private managed-care hospitals, factors that are far less common here. "There are multiple reasons for the declining [Canadian] rate," says Dr Marie-Laure Brisson, Chief of Pathology at the Jewish General Hospital (JGH) in Montreal, a passionate advocate for the continued practice of autopsy. She has watched in frustration as the number of autopsy presentations delivered at grand rounds has gone from two per week to two per year.

"Autopsies are an essential element of quality assurance in the medical system," Dr Brisson insists. They're key to evaluating the accuracy of clinical diagnosis and the efficacy of various treatments, they help detect new diseases and also reveal significant changes in the manifestation of known illnesses. Uncovering the precise cause (or causes) of death — incompletely recognized in up to 25% of patients — provides crucial epidemiological data. Moreover, autopsies are an invaluable teaching tool that can improve medical education at every level, from med students through to veteran practitioners.

I don't see dead people
"A main cause of the decline of autopsies is physicians themselves," Dr Brisson says bluntly. Pathologists like her are often frustrated by the unwillingness of other doctors to request autopsies in the first place. The widespread availability of MRI, CT and PET scanners encourages many doctors to jettison older practices like autopsy. These scans are quick, noninvasive and have greatly expanded diagnostic options. But Dr Brisson wants to get the point across that neglecting autopsies has serious consequences. "It's been well documented in numerous studies through the years that the number of cases where there are still important findings to discover through autopsy has not significantly decreased," she says. "There are cases where the MRI will catch a 1cm lesion, and miss a 5cm one. I have personally seen this, and the only way to discover the truth has been through autopsy and an examination of tissue under the microscope."

A recurring theme in all the commentary on autopsy is lack of time and resources — and a lack of urgency. Dr HJ Mitnick, a family physician at the Herzl Family Institute at the JGH, acknowledges that there's a strong trend against requesting autopsies. But he says that it's usually because there's no pressing need for the procedure. "Inpatients today are so sick that isolating one cause of death from a wide array of symptoms would serve no purpose for the family," he says.

A matter of consent
Even if a doctor wants an autopsy, getting consent from the family isn't always possible. It's certainly easier to get consent when there are concerns about genetic conditions that could potentially affect surviving family members. And fetal autopsies are encouraged so the parents can learn more about risks of any future pregnancies. It's all about engaging with families before death, preparing them for the outcome and establishing a basis of trust. But this takes time — a precious commodity for doctors who have throngs of the living to tend. All the same, having a resident on a new rotation ask permission for such an emotionally sensitive procedure over the phone isn't such a great idea either. Dr Mitnick agrees that doctors' approach to the issue could be improved, but he notes that physicians receive little formal training in requesting autopsies from grieving families. And sometimes it's all in the asking. "Often doctors, when they do ask, use a manner that gives an easy out — 'You don't want an autopsy, do you?' Our lack of enthusiasm is clear."

Perhaps the most difficult set back Canada faces is the lack of qualified and motivated pathologists. "We are unbelievably short of pathologists in Quebec," says Dr Brisson. "The situation is similar across Canada. Autopsies are poorly reimbursed by the Régie de l'assurance maladie du Québec." Another issue is that the number of complicated medical tests and procedures performed by pathologists — particularly in the treatment of cancer — has grown exponentially in the last few decades, paralleling the decline in the autopsy rate. Then there's the workload generated by academic centres, where large-scale studies are conducted on an ongoing basis.

When prioritizing cases, most pathologists simply have no time left for autopsies. A thorough pathologist takes a minimum of a half-day to complete an autopsy, but more often than not it will consume a full day of work, especially with elderly patients, who have significantly more comorbidities. Competing priorities and lack of funds spur a form of self-protection among pathologists, who grow reluctant to take on procedures that they feel are undervalued. The downward trend towards conducting fewer autopsies ends up getting reinforced even further.

For her part, Dr Brisson has no illusions. "Autopsies are not sexy. Who gets up in the morning and thinks 'I hope I have two autopsies to do today?' Nobody. But once you're doing them, it's always interesting. It's always possible to find something new and relevant."