Report and Recommendations of the Association of Pathology Chairs' Autopsy Working Group

[A European comparison of continuing education in pathology]

In the coming years, the shortage of pathologists will become internationally evident. In addition, the increase in knowledge, technical transformation processes, and the attractiveness of working conditions pose clear challenges for the field of pathology. A bi-directional opening for international mobility of pathologists could be a potential solution.In this analysis, the European training concept of the European Union of Medical Specialists (UEMS) was compared with its implementation in the 27 countries of the EU plus its 4 associated countries with regard to nationally differentiated concepts, type and implementation of the specialist examination, and additional qualifications. Subsequently, questions regarding the recognition of exams, titles, and specialist exams were elicited.The duration of training ranges between 4 and 6 years. The number of cases also varies considerably. Obtaining the specialist title can be done by simply completing the specifications up to a structured examination. In the EU, exams are mutually recognized, but this does not necessarily apply to academic titles and additional qualifications. Increasingly, on-site training centers are also subject to auditing procedures.The European agreements allow a high degree of permeability. However, national regulations pose hurdles for international mobility. The UEMS is therefore focusing on harmonization, including the certification of training centers. The so-called European Pathology Progress Test of the European Society of Pathology (ESP) is a further step towards the development of a future European specialist title. It remains the joint responsibility of residents and institutes to shape the future of the next generation of pathologists from the variety of different concepts.

The Gallbladder and Vermiform Appendix as Quality Assurance Indicators in Autopsy Pathology

OBJECTIVES

We investigate the number of autopsy reports that did or did not document the presence or absence of the gallbladder or appendix or document abdominal scars in patients following cholecystectomy or appendectomy. We also report gallbladder and appendix pathology at autopsy.

METHODS

Autopsy reports from patients 18 years or older autopsied at a community teaching hospital between January 1, 2009, and December 31, 2018 were reviewed. Nonabdominal autopsies were excluded. Histopathologic examination of the gallbladder and appendix was only performed if gross pathology was seen.

RESULTS

Of the 385 autopsies studied, 48 (12.5%) had cholecystectomies, of which 6 (12.5%) did not document abdominal scars. Sixty-two (16.1%) had appendectomies, of which 12 (19.4%) did not document abdominal scars. The presence or absence of the gallbladder and appendix was not documented in 6 (1.6%) and 16 (4.2%) of reports, respectively. Pathology was seen in 87 (25.8%) gallbladders and 4 (1.2%) appendixes.

CONCLUSIONS

Absence of the gallbladder or appendix is a relatively common autopsy finding. Auditing autopsy reports for documentation of their presence or absence, along with associated abdominal scars, are potential quality assurance indicators of autopsy reports. Documentation of these elements could be improved by changing the autopsy template or using synoptic reporting.

Autopsy Education in Canadian Pathology Programs: A Survey of Canadian Trainees

INTRODUCTION

This survey of Canadian pathology residents was designed to quantify the number of autopsies Canadian residents aim to complete during residency training, to better understand the perception of residents about access and quality of autopsy skills education. In addition, the interest of current pathology residents in autopsy and forensic pathology as a future career was also assessed.

METHODS

A web-based survey was sent to all Canadian pathology residents. This survey consisted of 19 questions on institution, level of training, intention to complete the American Board of Pathology examination, number of autopsies completed, perception of quality/access to autopsy skills education, interest, and factors contributing to autopsy and forensic pathology.

RESULTS

Eighty two (26%) of a possible 310 residents (12/47 general pathology, 70/263 anatomical pathology) across all Canadian institutions offering anatomical or general pathology programs (16/16 institutions) participated in the survey. Eighty-three percent of the respondents rated autopsy education as either very important or important. Fifty-five percent of the respondents intended to either challenge the American Board of Pathology examination or wanted the option to do so in the future, whereas only 47% of the participants agreed that all residents who wish to challenge the examination will easily be able to complete 50 autopsies during residency. Only 18% of the respondents were interested in performing autopsies as a major part of their career, and a combined 52% were only interested in performing autopsies to secure a desired position or felt that having to do autopsies would be a job deterrent. The quality of autopsy teaching received and the number of autopsies performed was identified as the most significant factors affecting interest in performing autopsies as part of a future career. A combined 68% of the respondents felt that the job market in forensic pathology in Canada was either good (better than most subspecialties) or very good (more jobs than graduating fellows). Seventy-one percent (12/17) of postgraduate year 5 respondents reported having completed 50 or more autopsies at the time of survey completion. Eleven percent of the respondents did not agree that all residents who document having completed an autopsy at their institution will have participated in all 8 essential autopsy tasks. Twenty four (29%) of the 82 respondents provided detailed narrative comments.

DISCUSSION

Most Canadian pathology residents believe that autopsy education is an important component of residency training. Limited access to quality autopsy teaching seems to be an important factor in resident interest in forensic pathology as a future career, despite a perceived good job market in comparison with most other subspecialties.

Why Should Clinical Autopsies Continue to Exist?

At some point in history, medicine was integrated with pathology, more precisely, with pathological anatomy [...].

Autopsies in pandemics - a perspective on barriers and benefits. Is it time for a revival?

Influenza virus and coronavirus pandemics regularly sweep the globe, at great cost of health and economy. Our aim was to conduct a PubMed search for autopsy studies on influenza and coronavirus to investigate the contribution of autopsies during pandemics, focussing on autopsy methods and procedures and the role of autopsy findings in pandemics. The retrieved autopsy studies generally relied on microscopy, polymerase chain reaction (PCR), immunostaining and electron microscopy. Most were small and reported on lung effects, including diffuse alveolar damage (DAD), pneumonia and tracheobronchitis. Antibiotic therapy has diminished a role for bacterial pneumonia, whereas obesity is an emerging risk factor. Autopsy studies have provided new insights into coronavirus disease 2019 (COVID‐19) treatments like anti‐coagulative therapy. Unfortunately, autopsies during pandemics are hampered by lack of guidelines, facilities and expertise for handling potentially infectious corpses and by widely varying recommendations for personal protective equipment and procedures. The Department of Forensic Pathology, at the Forensic Institute, at the University of Copenhagen in Denmark has, in collaboration with the Department of Pathology, Rigshospitalet, Copenhagen, initiated a prospective observational study on COVID‐19‐related deaths encompassing postmortem imaging, standardized autopsy procedures/reporting and extensive tissue sampling for histological, chemical, microbiological and genetic analysis. The study involves a diverse array of research groups at the University of Copenhagen, and the clinical field.

Could COVID-19 Trigger a Rebirth in Anatomy Education? A Glimpse of Anatomists' Responses to Pandemics of the Past and Present

Pandemics are nothing unusual but indeed lead to devastating effects that play a pivotal role in reshaping human history. The COVID-19 outbreak is currently responsible for major educational crises globally as most of the world has been faced with a mandated lockdown, and forced closure of educational institutions, including medical colleges. Anatomists have therefore been challenged to unlock technology in effort to achieve best deliverables for their discipline, without the use of traditional teaching aids such as the cadaver, osteological banks, prosected specimens, models, and microscopic slides. At present, the virtual classroom is the only option for the anatomist, thereby omitting vital aspects of the hidden curriculum such as ethical-reasoning, empathy, respect, professionalism, interpersonal, and communication skills. As body donations dwindle, the era of teaching in a cadaverless environment is upon us. This marks the beginning of a paradigm shift in education and research for anatomists worldwide. Given the variable pathological-morphological presentation in COVID-19-related deaths, it is also likely that the autopsy component of anatomic pathology will be resuscitated to demystify the underlying mechanisms of the virus. Since COVID-19 may never disappear completely, we would like to recommend that international anatomical societies collectively reach out to statutory bodies to devise a standardized method of teaching anatomy, employing readily available cost-effective resources, in the face of pandemics. However, if anatomy as a discipline has survived a millennium, surely anatomists can fight the “scourges” that have plagued them as various perspectives have been bandied about to welcome in a new normal.

Autopsy Service Death Certificate Review

CONTEXT.—

Despite the importance of accurate death statistics for epidemiologic studies and public health initiatives, there remains a high frequency of errors in death certification. This deficiency can be addressed by the hospital autopsy service.

OBJECTIVES.—

To improve the quality and accuracy of death certificates issued in the hospital and improve resident and clinician education by initiating a death certificate review process, performed by pathology residents while on their hospital autopsy rotation.

DESIGN.—

A resident reviewed all death certificates issued in the hospital daily through the state electronic death certificate filing system and correlated with the decedent's medical record. When errors were found, the resident filed an amended death certificate with the state. If applicable, the Office of the Medical Examiner was contacted to investigate. The original certifying physician was then contacted via email with an explanation for the amendment.

RESULTS.—

In 12 months, 590 death certificates were issued by the hospital. Eighty-eight of 590 (15%) were amended. Of those 88 amended, 41 (47%) were missing an underlying cause of death, 7 (8%) had an inaccurate cause of death, 41 (47%) failed to include relevant contributory causes of death, and 17 (19%) had major typographic errors. Of 88, 24 (27%) fell under the Office of the Medical Examiner's jurisdiction and were reported with a subsequent change in the manner of death in 23 of 88 cases (26%).

CONCLUSIONS.—

Death certificate review by the autopsy service improves the accuracy of death certification, impacts resident and clinician education, and serves as quality assurance for both the hospital and the state.

Second opinion system for sudden cardiac death cases in forensic practice

Sudden cardiac death (SCD) represents a considerable percentage of cardiovascular deaths worldwide. The most frequent pathological substrate of SCD is atherosclerotic coronary artery disease (CAD). The other, less common, pathologies which can cause SCD include cardiomyopathies, congenital diseases (including abnormal anatomy), and arrhythmias such as channelopathies, many of which are genetically determined. Autopsies of SCD victims are generally performed by forensic pathologists. In some cases, a third person responsibility could be invoked. While CAD diagnosis at post-mortem examination is not a major challenge for the forensic pathologist, the other rarer diseases may be. In such instances, referral of the hearts to specialized centers with recognized expertise is recommended, and this is particularly important in cases of SCDs of young people. Moreover, in order to avoid the frequent overdiagnosis of a pathological heart, an expert opinion should be sought for even in the presence of a morphologically normal heart. In cases where retention of the heart is not feasible, it is essential to provide an extensive photographic documentation, with the indication of the sampling sites for histological examination. However, some practical aspects, as the criteria for case selection in routine forensic practice are missing. In this paper, we present the recommendations for heart retention for a second expert opinion and the alternative of documentation and sampling for cases where retention is not possible.

The Importance of the Autopsy in Medicine: Perspectives of Pathology Colleagues

This article presents a perspective on the importance of the autopsy in medical practice and science based on experiences of the authors as physician-scientists involved in autopsy practice. Our perspectives are presented on the seminal contributions of the autopsy in the areas of cardiovascular disease, including congenital heart disease, atherosclerosis, coronary artery disease, and myocardial infarction, and infectious disease, including tuberculosis and viral infections. On the positive side of the future of the autopsy, we discuss the tremendous opportunities for important research to be done by application of advanced molecular biological techniques to formalin-fixed, paraffin-embedded tissue blocks obtained at autopsy. We also note with concern the countervailing forces impacting the influence of pathology in education and clinical practice at our academic medical centers, which also present impediments to increasing autopsy rates. Our challenge as academic pathologists, whose careers have been molded by involvement in the autopsy, is to counter these trends. The challenges are great but the benefits for medicine and society are enormous.

Position Paper From the Association of Pathology Chairs: Assessing Autopsy Competency in Pathology Residency Training

Declining numbers of hospital autopsies performed in US pathology residency training programs and perceived declining practice of autopsy by many pathologists has caused stakeholder organizations to reassess the role of autopsy training in pathology residency. A working group convened by the stakeholder organizations has delivered the results of a detailed study of current practice of autopsy education in US pathology programs, along with recommendations for the future of autopsy education. Accepting the report of the Working Group, the Association of Pathology Chairs here publishes its position paper on the proposed recommendations.