Autopsies have been an important part of medical education and practice, but over the last 50 years they've been performed far less frequently -- and doctors may be missing out on useful information, according to a
Older physicians may recall regular visits from the pathologist to confirm or disprove their diagnoses, and these were "a form of audit for the whole medical team," according to Kevin De Cock, MD, the Kenya country director for the CDC, and colleagues. "The experience could be humbling or reassuring, but it was always a deterrent to medical hubris."
Now, autopsies in the U.S. are typically reserved for cases in which a death is suspicious or a crime is suspected, De Cock said.
"Much more can be learned from the dead," he told 鶹ý.
There are many reasons for the decline: attempts to reduce healthcare costs; concerns about litigation if errors are identified; greater cultural aversion to interfering with cadavers.
De Cock also pointed to "our own medical hubris," in an interview with NEJM. "Our ability to investigate living patients clinically is so much better than it was in previous decades, so the assumption is, we don't need to be doing this anymore," emphasizing a rise in "medical overconfidence because of increased diagnostic and therapeutic capacities."
But according to data from full autopsies, the rate of misdiagnoses and mistakes hasn't changed much over time, hovering around 30%, he said.
Judy Melinek, MD, a forensic pathologist based in San Francisco, highlighted a estimating that if an average U.S. hospital performed autopsies after all deaths, it would detect class I errors -- those that "would have resulted in a change in therapy and might have prolonged survival if identified earlier," she said -- in about 4% of cases, and class II errors -- "missed diagnoses that didn't affect survival but were still clinically important" -- in an additional 4%.
"Pathologists and academic physicians are very concerned about the international drop in autopsy rates," Melinek said.
While full autopsy remains the gold standard, De Cock noted that less invasive methods of postmortem examination have been developed, and could be applied in specific situations.
In Nairobi where De Cock is based, for instance, tissue sampling of cadavers for HIV has enabled researchers to calculate excess deaths due to the condition. In West Africa, oral swabs and subsequent testing have helped identify additional clusters of Ebola outbreaks that weren't previously suspected, and liver biopsies can help countries better estimate rates of hepatitis B and C, he said.
"Virtual" autopsies that rely on CT or MRI could also be another means of gleaning certain types of information, as well as "verbal" autopsies involving interviews with family members, particularly in low- and middle-income countries, De Cock wrote.
But Melinek cautioned about the limits of less-invasive means of "gleaning information about disease and death."
"These may be sufficient in cases where families have religious objections to autopsy, but they only answer the questions people know to ask," Melinek said. "As a forensic pathologist, I have seen radiology misidentify natural anomalies as injury, or miss fatal injuries that were too small to see radiographically and were only picked up by gross and microscopic analysis."
"If 'virtual autopsies' become the standard of postmortem care," she said, "then we will never know what we may be missing."
De Cock said it's time for a "global research and public health agenda that focuses on learning from the dead."
"We hope our paper will stimulate broader debate and result in a change of attitudes and practice," he told 鶹ý. "There is much to learn from the world's decedents and currently this global body of information is underutilized."