Autopsy and Verbal Autopsy Seeking the Deadly Truth Kate Conway M D MPHP 439 April 24th 2008 Introduction This chapter will explore the topic of autopsy and the developing practice of verbal autopsy First we highlight the historical perspective of the classic autopsy current national initiatives and then the challenges facing the age old practice Next we turn to the global significance of accurate vital statistics barriers to classic autopsy abroad and then what the verbal autopsy has to offer in its place By the end of this chapter you should be able to consider the verbal autopsy as a valid and necessary approach for acquiring accurate cause specific mortality data in developing countries Possible utilization of the verbal autopsy in the developed world and maximizing the practice of classic autopsy will also be addressed at the end The Autopsy The term autopsy means to see for oneself and is also known as a postmortem examination necropsy or obduction It refers to a medical procedure performed by a specialized medical doctor called a pathologist They can be performed for either legal or medical purposes When the cause of death may be a criminal matter a forensic autopsy may be performed to investigate and gather evidence A clinical or academic autopsy is performed with the next of kin s permission when cause of death is unclear or for research purposes 1 Even though the concept and general practice of autopsy has been around for more than a millennium Giovanni Morgagni a physician and professor at the University of Padua is credited for being the autopsy s intellectual founder 2 In his text The Seats and Causes of Disease Investigated by Anatomy published in 1761 Morgagni describes 700 autopsies performed 2 Many credit him for being one of the first to present the then new idea of disease as a traceable logical entity instead of a result of humors or spirits 2 Another important name in the history of autopsy is William Osler a Canadian physician who practiced and taught medicine in the United States in the late 1800 s Medical students today have him to thank for the current model of medical education where they enter their critical clinical training during the third year of medical school The autopsy was placed at the center of this education He performed greater than a thousand post mortems and insisted that staff and students dedicate time to them as well 2 The power of autopsy was further exposed by Richard Clarke Cabot in the early 1910 s He reviewed thousands of autopsy records from patients at Massachusetts General Hospital and found the clinical diagnoses to be wrong about 40 of the time The rates of autopsies being performed began to rise and by World War II they became part of standard medical school curriculum 2 The autopsy is credited for the reduction in morbidity and mortality from certain medical conditions like aortic dissections for example Similarly they also played central roles in diagnosing and spurring treatment for sudden infant death syndrome Legionnaires disease toxic shock syndrome hantavirus H I V Ebola and other infectious diseases and even assisted in making the association between lung cancer and smoking 2 2 In the history of medicine as well as in the current modern medical world nothing else compares to the hospital autopsy for unveiling medical errors and oversights Dr Alan Schiller is chairman of pathology at Mount Sinai School of Medicine in New York A contemporary champion of the low tech hospital autopsy he feels that it provides a uniquely effective means of quality control and knowledge even in today s high tech medical world 2 Schiller says it is the most powerful tool in medicine exposing mistakes bad habits it evaluates diagnostic and treatment routines and detects new disease it is responsible for most of our knowledge of anatomy and disease and it remains vital 2 In a 1998 article Dr George Lundberg a pathologist and editor for The Journal of the American Medical Association JAMA published an article in 1998 reviewing discrepancies between clinical diagnoses and autopsy findings He reported that numerous studies over the last century have found an undiagnosed cause of death in 2540 of cases where autopsy was performed 2 The findings were very similar to the first discrepancy studies in 1910 low tech autopsy trumps high tech medicine again and again 2 Medicine assumes that the information on death certificates is accurate and dependable However the published medical literature reveals another truth One study by Ravakhah looked at the accuracy of death certificates in reporting vital statistics with an emphasis on cardiac deaths His investigation revealed frequent major discrepancies of commission and omission between death certificates and autopsy The death certificate missed acute myocardial infarction in 25 of 52 autopsy proven cases and conversely it wrongly asserted the presence of an acute myocardial infarction in 9 36 cases 3 A recent meta analysis and review by Roulson et al claims that at least a third of 3 death certificates are likely to be incorrect and 50 of autopsies produce findings unsuspected before death 4 Despite its known power for truth the autopsy has been neglected by the very institutions that originally brought it to the forefront of medical practice In the 1960s hospitals in the United States autopsied almost half of all deaths Hospitals in the US now perform autopsies on fewer than 5 of hospital deaths 2 When Dr Lunberg talks to doctors groups or health care policy makers they all generally agree that more autopsies need to be performed However nobody seems to put that agreement into action the forces arrayed against the autopsy regulatory economic and cultural seem to overcome any impulse to revive it 2 The neglect of autopsy seems to be multi factorial First there are the many pathologists who don t like doing them The procedure can take between 2 4 hours and takes away time spent on urgent analysis of samples taken from living patients Careers and status are seldom advanced with the practice of autopsy and most hospitals don t pay extra for their special skill 2 Money is the hospital s excuse for decreasing the number of autopsies performed Insurance usually doesn t cover the estimated 2 000 4 000 ticket price and most families can t afford to pay it themselves after funeral and medical bills 2 From about the 1950s to the 1970s the Joint Commission on Accreditation of Healthcare Organization JACHO held a