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decisionsarebasedinpartonvitalstatisticsandotherestimatesofdiseaseburden.
Autopsymeanstoseeforoneself.
Itwouldbeasfoolishtothinkwehavereachedthelimitsofhumanknowledgeasitistothinkwewillsomedayknoweverything.
Thereisalways,andwilleverbe,scopeforimprovement,tolearnfromknowingwhenourcertaintiesaresimplywrong.
GemaFrühbeckclinicalscientistDepartmentofEndocrinology,MedicalSchool,UniversityofNavarra,31008Pamplona,Spaingfruhbeck@unav.
esCompetinginterests:Nonedeclared.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)2BurtonEC,TroxclairDA,NewmanWPIII.
Autopsydiagnosesofmalignantneoplasms.
HowoftenareclinicaldiagnosesincorrectJAMA1998;280:1245-8.
3GoldmanL,SaysonR,RobbinsS,CohnLH,BettmannM,WeisbergM.
Thevalueoftheautopsyinthreemedicaleras.
NEnglJMed1983;308:1000-5.
4ShojaniaKG,BurtonEC,McDonaldKM,GoldmanL.
Changesinratesofautopsy-detecteddiagnosticerrorsovertime.
Asystematicreview.
JAMA2003;289:2849-56.
5LynnJ,CobbsE,OrensteinJ.
Autopsyratesanddiagnosis.
JAMA1999;281:2181.
InHongKongteachingautopsieshavebeenchampionedinpublicmortuariesEditor—O'Grady'scommentsontheteach-ingautopsyresonateformanyofus.
1WeinHongKonghavealsoexperiencedthegradualgeneraldecreaseinthenumberofhospitalautopsiessuchthatthismajorteachinghospitalseesonly20-30casesayear.
Thiscoupledwiththeswitchtoaprob-lembasedlearningmedicalcurriculumin1997broughtautopsyteachingtothevergeofextinction.
Wehave,however,preservedautopsyteachingformedicalstudentswiththehelpofcolleaguesinthepublicmortuaries,whereover4000coroners'autopsiesareperformedeachyear.
Duringthesecondyearrotations,medicalstudentsingroupsof8-10observeadetailedautopsyofacaseorinsomeinstancessnapshotsofmanycases.
Theyarerequiredtowriteabouttheirexpectationsofsuchasessionandtoreflectontheirexperienceafterwards.
Wehavealsoredesignedourteachingclinicopathologicalconferences.
Studentsareallocatedacaseandareprovidedwiththecasenotes,radiographs,andbiopsyandautopsyreports,etc,fortheirpresentationtotheclass.
Teachershaveonlyawatchingbrief.
Atotalofninesuchsessionsareheldinthethirdyearofthecurriculum.
Unfortunately,thecurriculumcannotaccommodatemoreautopsyteachingses-sions.
Furtherautopsyteachingisavailabletostudentsonlyasspecialstudymodules.
Thismeansofresuscitatingtheteachingautopsyispossiblebecause,asintheUnitedKingdom,thereisnoexplicitinterpretationofourcoroners'ordinancethatprohibitstheattendanceofautopsiesfortheteachingofmedicalstudents,policeofficers,etc.
PhilipSLBehclinicalassistantprofessor(forensicpathology)DepartmentofPathology,FacultyofMedicine,QueenMaryHospital,HongKongphilipbeh@pathology.
hku.
hkCompetinginterests:PSLBcoordinatestheautopsyteachingandtheclinicopathologicalteachingsessionsofundergraduatemedicalstudents.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)AutopsyisasuccessstoryinCubaEditor—Advancesinsophisticatedante-mortemdiagnosticmethodsmayhavereducedthevalueofautopsy.
1Thepercent-ageofdeathswithoutclinical-pathologicalconcordancehasnotdecreaseddespitemoderndiagnostictechnologies.
2Indeed,incertaincasesthesenewmethodshavemisledthediagnosis,partlybecauseofdoctors'excessiveconfidenceinthem.
Oursisthemainprovincialhospitalforadultpatientswithclinicalandsurgicaldisorders.
Allservices,includingautopsy,arefreeofcharge,asintherestofCuba.
Thehospitalhas520bedsandmorethan15000admissionsandabout1100deathsyearly.
Sinceitsopening24yearsago,autopsyhasbeenperformedonmorethan80%ofcases.
Consenttoautopsyisalwaysvoluntaryandobtainedfromrelativesoraproxyafteradetailedexplanationofallbenefitsofthepostmortemexaminationbytheclinician(s)inchargeofthepatient.
Familiescanaskquestionsabouttheprocedureandaretoldwhenthefinalreportwillbecomeavailable.
3Learningfromautopsyisoneofthemostsuccessfulactivitiesofthepathologydepart-ment.
Threeanatomic-clinicalsessionsforspecialists,residents,interns,andstudentsfromthirdyearupwardsoccurweekly.
Herethecasesofmorethanhalfofallpatientswhohavediedarediscussedsoonaftertheirdeathwiththefirstresultsofthepostmortemexamination.
Aclinical-pathologicalconfer-enceisperformedmonthlywithdemonstra-tionsofcasesforallmedicalstaff.
Whenthefinalautopsyreportsareavailable,allclinicalchartsarereviewedanddiscussedagainatthemonthlymeetingofthehospital'scommitteeofmortalityanaly-sis,anotherusefulteachingsession.
Thecausesofdeathrecordedincertificatescanberewrittentoimprovethequalityofthecountry'svitalstatisticswhenerrorsinclini-caldiagnosishaveoccurred.
AlfredoEspinosa-Britoprofessor,departmentofinternalmedicineespinosa@perla.
inf.
cuJulianViera-Yanizprofessor,departmentofpathologyOsmelChavez-Troyadoctor,departmentofinternalmedicineRaulNieto-Cabreradoctor,departmentofinternalmedicineHospitalDrGustavoAldereguiaLima,Ave5deSeptiembreandCalle51A,Cienfuegos,55100,CubaCompetinginterests:Nonedeclared.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)2GoldmanL,SaysonR,RobbinsS,CohnL,BettmannM,WeishbergM.
Thevalueoftheautopsyinthreemedicaleras.
NEnglJMed1983;308:1000-5.
3McDermottMB.
ObtainingconsentforautopsyBMJ2003;327:804-6.
(4October.
)HistopathologistsshouldnotobtainconsentforautopsyEditor—McDermottacceptsthatheisinconflictwithhisprofessionalbodieswhenhechampionstheideaofconsultanthistopathologistsbeingresponsibleforobtainingconsentforautopsy.
1Hedescribesaseriesofpre-autopsymeetings.
These"oftendifficultnegotia-tions"withfamiliescoveredahighpro-portionofthe83autopsiesheperformedinthe32monthsunderstudy.
Theyusuallyincludedinputfromamemberofclinicalmedicalstaff,aconsultantpathologist,asocialworker,nursingstaff,withorwithoutachaplain.
Adisproportionate46%ofmeet-ingsorautopsyrelatedworkoccurredduringaweekendorpublicholiday.
Hestatesthatthisworkhadtotakeprecedenceoverotherwork—presumablydiagnosticworkforlivingchildren—andpresumablyalsooverhisfamilylife.
Hisenthusiasmislaudable,butheisliv-inginacompletelydifferentworldfromtherestofus.
Eightythreeautopsiesin32monthsisequivalentto31ayear.
Inmydepartmentweeachdoabout140ayearinadditiontoanindividualdiagnosticwork-loadofadultcytologyandbiopsyandresectionspecimensthatisseveralmultiplesofapaediatricpathologist'sannualquota.
Acostpercaseanalysisofhisautopsypractice,includingthecostsofancillarystaff,wouldbeinformative.
Manypathologistsdidnot,andmanytraineeswillnot,enterthespecialtywithadesireorabilitytoembarkonnegotiationswithgrievingrelativesandsocialworkers.
Clinicans,whoalreadyhavearelationshipwiththefamilyandcanexplaintheclinicalbenefitstobederivedfromtheresultsofanautopsyshouldrequesttheexaminationiftheybelievethatitwillbeofbenefittothefamilyorfuturesiblings.
Ofcoursepatholo-gistsmustsupportclinicianswithtrainingandexplanationofwhattheprocedurewillentail.
SimonRoseconsultanthistopathologistDepartmentofCellularPathology,RoyalUnitedHospitalBathNHSTrust,BathBA13NGsimon.
rose@ruh-bath.
swest.
nhs.
ukCompetinginterests:Nonedeclared.
1McDermottMB.
Obtainingconsentforautopsy.
BMJ2003;327:804-6.
(4October.
)MsHUNTER9f.
36r/GLASGOWUNIVERSITYLIBRARY/BALLetters166BMJVOLUME32817JANUARY2004bmj.
com
Autopsymeanstoseeforoneself.
Itwouldbeasfoolishtothinkwehavereachedthelimitsofhumanknowledgeasitistothinkwewillsomedayknoweverything.
Thereisalways,andwilleverbe,scopeforimprovement,tolearnfromknowingwhenourcertaintiesaresimplywrong.
GemaFrühbeckclinicalscientistDepartmentofEndocrinology,MedicalSchool,UniversityofNavarra,31008Pamplona,Spaingfruhbeck@unav.
esCompetinginterests:Nonedeclared.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)2BurtonEC,TroxclairDA,NewmanWPIII.
Autopsydiagnosesofmalignantneoplasms.
HowoftenareclinicaldiagnosesincorrectJAMA1998;280:1245-8.
3GoldmanL,SaysonR,RobbinsS,CohnLH,BettmannM,WeisbergM.
Thevalueoftheautopsyinthreemedicaleras.
NEnglJMed1983;308:1000-5.
4ShojaniaKG,BurtonEC,McDonaldKM,GoldmanL.
Changesinratesofautopsy-detecteddiagnosticerrorsovertime.
Asystematicreview.
JAMA2003;289:2849-56.
5LynnJ,CobbsE,OrensteinJ.
Autopsyratesanddiagnosis.
JAMA1999;281:2181.
InHongKongteachingautopsieshavebeenchampionedinpublicmortuariesEditor—O'Grady'scommentsontheteach-ingautopsyresonateformanyofus.
1WeinHongKonghavealsoexperiencedthegradualgeneraldecreaseinthenumberofhospitalautopsiessuchthatthismajorteachinghospitalseesonly20-30casesayear.
Thiscoupledwiththeswitchtoaprob-lembasedlearningmedicalcurriculumin1997broughtautopsyteachingtothevergeofextinction.
Wehave,however,preservedautopsyteachingformedicalstudentswiththehelpofcolleaguesinthepublicmortuaries,whereover4000coroners'autopsiesareperformedeachyear.
Duringthesecondyearrotations,medicalstudentsingroupsof8-10observeadetailedautopsyofacaseorinsomeinstancessnapshotsofmanycases.
Theyarerequiredtowriteabouttheirexpectationsofsuchasessionandtoreflectontheirexperienceafterwards.
Wehavealsoredesignedourteachingclinicopathologicalconferences.
Studentsareallocatedacaseandareprovidedwiththecasenotes,radiographs,andbiopsyandautopsyreports,etc,fortheirpresentationtotheclass.
Teachershaveonlyawatchingbrief.
Atotalofninesuchsessionsareheldinthethirdyearofthecurriculum.
Unfortunately,thecurriculumcannotaccommodatemoreautopsyteachingses-sions.
Furtherautopsyteachingisavailabletostudentsonlyasspecialstudymodules.
Thismeansofresuscitatingtheteachingautopsyispossiblebecause,asintheUnitedKingdom,thereisnoexplicitinterpretationofourcoroners'ordinancethatprohibitstheattendanceofautopsiesfortheteachingofmedicalstudents,policeofficers,etc.
PhilipSLBehclinicalassistantprofessor(forensicpathology)DepartmentofPathology,FacultyofMedicine,QueenMaryHospital,HongKongphilipbeh@pathology.
hku.
hkCompetinginterests:PSLBcoordinatestheautopsyteachingandtheclinicopathologicalteachingsessionsofundergraduatemedicalstudents.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)AutopsyisasuccessstoryinCubaEditor—Advancesinsophisticatedante-mortemdiagnosticmethodsmayhavereducedthevalueofautopsy.
1Thepercent-ageofdeathswithoutclinical-pathologicalconcordancehasnotdecreaseddespitemoderndiagnostictechnologies.
2Indeed,incertaincasesthesenewmethodshavemisledthediagnosis,partlybecauseofdoctors'excessiveconfidenceinthem.
Oursisthemainprovincialhospitalforadultpatientswithclinicalandsurgicaldisorders.
Allservices,includingautopsy,arefreeofcharge,asintherestofCuba.
Thehospitalhas520bedsandmorethan15000admissionsandabout1100deathsyearly.
Sinceitsopening24yearsago,autopsyhasbeenperformedonmorethan80%ofcases.
Consenttoautopsyisalwaysvoluntaryandobtainedfromrelativesoraproxyafteradetailedexplanationofallbenefitsofthepostmortemexaminationbytheclinician(s)inchargeofthepatient.
Familiescanaskquestionsabouttheprocedureandaretoldwhenthefinalreportwillbecomeavailable.
3Learningfromautopsyisoneofthemostsuccessfulactivitiesofthepathologydepart-ment.
Threeanatomic-clinicalsessionsforspecialists,residents,interns,andstudentsfromthirdyearupwardsoccurweekly.
Herethecasesofmorethanhalfofallpatientswhohavediedarediscussedsoonaftertheirdeathwiththefirstresultsofthepostmortemexamination.
Aclinical-pathologicalconfer-enceisperformedmonthlywithdemonstra-tionsofcasesforallmedicalstaff.
Whenthefinalautopsyreportsareavailable,allclinicalchartsarereviewedanddiscussedagainatthemonthlymeetingofthehospital'scommitteeofmortalityanaly-sis,anotherusefulteachingsession.
Thecausesofdeathrecordedincertificatescanberewrittentoimprovethequalityofthecountry'svitalstatisticswhenerrorsinclini-caldiagnosishaveoccurred.
AlfredoEspinosa-Britoprofessor,departmentofinternalmedicineespinosa@perla.
inf.
cuJulianViera-Yanizprofessor,departmentofpathologyOsmelChavez-Troyadoctor,departmentofinternalmedicineRaulNieto-Cabreradoctor,departmentofinternalmedicineHospitalDrGustavoAldereguiaLima,Ave5deSeptiembreandCalle51A,Cienfuegos,55100,CubaCompetinginterests:Nonedeclared.
1O'GradyG.
Deathoftheteachingautopsy[withcommen-tarybyJUnderwood].
BMJ2003;327:802-4.
(4October.
)2GoldmanL,SaysonR,RobbinsS,CohnL,BettmannM,WeishbergM.
Thevalueoftheautopsyinthreemedicaleras.
NEnglJMed1983;308:1000-5.
3McDermottMB.
ObtainingconsentforautopsyBMJ2003;327:804-6.
(4October.
)HistopathologistsshouldnotobtainconsentforautopsyEditor—McDermottacceptsthatheisinconflictwithhisprofessionalbodieswhenhechampionstheideaofconsultanthistopathologistsbeingresponsibleforobtainingconsentforautopsy.
1Hedescribesaseriesofpre-autopsymeetings.
These"oftendifficultnegotia-tions"withfamiliescoveredahighpro-portionofthe83autopsiesheperformedinthe32monthsunderstudy.
Theyusuallyincludedinputfromamemberofclinicalmedicalstaff,aconsultantpathologist,asocialworker,nursingstaff,withorwithoutachaplain.
Adisproportionate46%ofmeet-ingsorautopsyrelatedworkoccurredduringaweekendorpublicholiday.
Hestatesthatthisworkhadtotakeprecedenceoverotherwork—presumablydiagnosticworkforlivingchildren—andpresumablyalsooverhisfamilylife.
Hisenthusiasmislaudable,butheisliv-inginacompletelydifferentworldfromtherestofus.
Eightythreeautopsiesin32monthsisequivalentto31ayear.
Inmydepartmentweeachdoabout140ayearinadditiontoanindividualdiagnosticwork-loadofadultcytologyandbiopsyandresectionspecimensthatisseveralmultiplesofapaediatricpathologist'sannualquota.
Acostpercaseanalysisofhisautopsypractice,includingthecostsofancillarystaff,wouldbeinformative.
Manypathologistsdidnot,andmanytraineeswillnot,enterthespecialtywithadesireorabilitytoembarkonnegotiationswithgrievingrelativesandsocialworkers.
Clinicans,whoalreadyhavearelationshipwiththefamilyandcanexplaintheclinicalbenefitstobederivedfromtheresultsofanautopsyshouldrequesttheexaminationiftheybelievethatitwillbeofbenefittothefamilyorfuturesiblings.
Ofcoursepatholo-gistsmustsupportclinicianswithtrainingandexplanationofwhattheprocedurewillentail.
SimonRoseconsultanthistopathologistDepartmentofCellularPathology,RoyalUnitedHospitalBathNHSTrust,BathBA13NGsimon.
rose@ruh-bath.
swest.
nhs.
ukCompetinginterests:Nonedeclared.
1McDermottMB.
Obtainingconsentforautopsy.
BMJ2003;327:804-6.
(4October.
)MsHUNTER9f.
36r/GLASGOWUNIVERSITYLIBRARY/BALLetters166BMJVOLUME32817JANUARY2004bmj.
com
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