Attending an autopsy assured me I had done all I could for my patient
Few medical students take part in postmortem examinations of patients that they have examined and cared for. However, it is a valuable way to demonstrate pathology and can help to keep physical examination relevant.
Physical examination at the bedside often demonstrates pathology on a superficial level. All students need to recognise clinical signs and perform physical examination techniques as part of diagnostic reasoning. When a patient they have examined dies in hospital, a student has a unique opportunity to supplement the physical examination and other information about the patient with the results of a postmortem examination. The correlation between the autopsy results and the clinical assessment of disease can be illuminating.
Leaders in medical education are concerned that over-reliance on laboratory tests and imaging data has led to an “atrophy of bedside evaluation skills.” They worry that future students will view their patients purely through electronic data on a computer screen and urge a return to the art of the bedside examination. The journey “back to the bedside” should include a stop at the morgue to reinvigorate students’ understanding of anatomy and how it correlates with the physical examination. I would add a call for a more formal return of the autopsy in medical education worldwide.
The non-forensic autopsy became an endangered species in the second half of the 20th century. The autopsy rate in the United Kingdom dropped from 43% in 1979 to 15% in 2001. Rates in France and the United States also decreased by more than half during this time. Reasons for the sharp decline include the attitudes of clinicians, the public, and even pathologists. Perhaps one misconception is that diagnostic testing is now so good that all relevant pathologies will have been found while the patient was alive. Studies show that autopsies still find major diagnostic errors. Postmortem examination is the gold standard by which we evaluate all premortem diagnoses.
Virtual autopsy by computed tomogram or magnetic resonance imaging scan has recently emerged as a promising tool. However, virtual autopsy is inferior for many diagnoses including myocardial infarction or pulmonary embolism and, of course, does not provide gold standard histological diagnoses. Instead, it might become an adjunctive tool for traditional medical postmortem examination.
I recently attended the autopsy of a patient I was involved in treating whose death followed the diagnosis of a new, widely metastatic lung adenocarcinoma. She had progressive respiratory failure, elected not to be resuscitated, and died suddenly while awaiting hospice care. At autopsy, I saw a fresh premortem clot sitting at the bifurcation of her pulmonary artery and helped the pathologist to remove it. Seeing her tumour in situ, in relation to surrounding vital structures, helped me to understand better her degree of organ dysfunction. I knew about her trace pericardial effusion, but the coarse texture of her cobblestoned pericardium near the tumour was a memorable finding.
In this patient’s final days I had been bothered by her left pleural effusion, which before death seemed on a radiograph to be enlarging. She had declined palliative drainage, but after her death I wondered if I should have tried harder to convince her. She might have had less dyspnoea in those final hours. I was surprised to see on autopsy that her tumour burden was much larger than even recent imaging would suggest. Her effusion was only a few hundred millilitres and not likely to be the main cause of her dyspnoea. These subtle postmortem conclusions reassured me as her doctor that I had done all I could for her.
Students taking part in postmortem examinations can see gross internal pathology in three dimensions. These unforgettable sights will replace the students’ textbook images of pathology such as empyema or liver metastases, which they may otherwise imagine while carrying out auscultation, percussion, and palpitation during a bedside physical examination. Physical and postmortem examinations complement each other, and continuing to carry out both will ensure that neither tool becomes obsolete. Students should make an effort to attend the autopsies of patients they have cared for and should also recommend postmortem examination to all dying patients and their families throughout their careers so that we can understand better the underlying causes of death.Benjamin T Galen, instructor of medicine
1Albert Einstein College of Medicine, Bronx, NY, USA
Correspondence to: firstname.lastname@example.org
Acknowledgment: I thank Andrew T Boyd and Jessica Ashley for their review of this manuscript and Egerton Davis for his insights.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h1904