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Once a cornerstone of medical education and medical practice, the autopsy has fallen into disuse and disregard in many circles in the USA. In this review of the autopsy today in the United States of America, I explore some of the values that should be exploited through autopsy study, the actual status of autopsy performance, and some of the initiatives that are being taken to counteract this trend.

A program for quality assessment of medical diagnostics is proposed, based on detailed, ongoing comparison of clinical diagnoses with autopsy diagnoses. The model requires that the autopsy service itself be subjected to quality control to assure the reliability of the autopsy findings, including the quality of diagnoses made postmortem, and the quality of autopsy reports. Discrepancies between premortem and postmortem diagnoses are classified as to cause and magnitude; for each disease, the total diagnostic experience is collected, and sensitivity and specificity of clinical diagnostics are computed. These are compared with control ranges of sensitivity and specificity, prospectively arrived at through analysis of thousands of cases. Statistically acceptable sampling for autopsy, and review of findings by an independent body are also discussed. The findings generated by this program would be of great value in programs for quality improvement of medical care. The model has the following advantages: (1) it recognises that there is an unavoidable baseline of diagnostic errors; (2) the control levels, based on current medical practice, are prospectively established; (3) it avoids placing blame in a single case; and (4) it provides a fairly high power scrutiny that can focus on diagnostics for single diseases rather than the entire spectrum of medical practice.

Autopsy practice today remains rooted in the fabric of medicine as it developed through the 18th and 19th centuries. Recent developments in medicine and society have left autopsy practice behind and have led to the decline of the autopsy. Potential new values of autopsies point strongly to the need for revitalized modern autopsy services, services focused on objectives and problems related to patients, their physicians, and the attendant societal issues. There are real values for pathology and pathologists, but only if major realignments in purposes and outcomes are forthcoming.

A national meeting of pathology educators in 1989 provided the impetus for an exploration of new uses of autopsy in medical education. A month before the conference, the authors sent a questionnaire about the uses and value of autopsy in medical education to 120 persons registered to attend the conference. They used the 98 responses, representing 69 U.S. and Canadian medical schools, as the basis of a workshop on the place of autopsy in future medical education. The present article is a report of the authors' findings from the questionnaire and workshop. They found that the uses of autopsy go far beyond the traditional uses in teaching clinical pathophysiology, clinico-pathologic correlations, clinical anatomy, gross and microscopic anatomy of disease, and visual skills. Emphasis was placed on the potential role of autopsy in education regarding legal/judicial proceedings, vital statistics, epidemiologic investigations, and public health, and in the understanding of such complex matters as medical fallibility, medical uncertainty, and grief. These purposes were seen as congruent with current societal concerns about the need to reverse the trend toward dehumanization of medicine and physicians. The inability to realize these aims in the face of a precipitous drop in the autopsy rate is discussed.

The use of autopsy in medical practice in the United States has declined drastically over the past 25 years. Physicians conduct post-mortem examinations on less than 12 percent of persons who die in hospitals and on proportionally far fewer people who die at home. Without due assessment of causes of death, pathologists lose opportunities to conduct critical diagnostic exercises, and society fails to obtain accurate health statistics. Medical practitioners, legislators, insurers, and the public should consider diverse features of a national policy for assuring that sufficient numbers of autopsies are competently performed and their findings appropriately employed.

The autopsy has been of great importance in educating students regarding medical uncertainty. The marked decline in the use of the autopsy in medical education and continuing education has contributed significantly to the current discomfort among physicians regarding medical uncertainty and medical errors, which, in turn, has furthered the decline of the autopsy. Inordinate guilt, denial, and other defensive behaviors that many physicians marshall in response to uncertainty and error prevent these individuals from learning from their mistakes. The autopsy experience during medical school, properly utilized, helps students to confront fallibility and sets the stage for later successful management of uncertainty and error.

The current state of death statistics in the United States would constitute a national embarrassment if it were not for the fact that the rest of the world seems to be similarly afflicted. This ubiquity of the issue does not, however, make it any less urgent. The etiology of the problem is multifaceted, and remediation will require a broad approach, designed to reach all of the several involved groups of people. The key to the solution, however, is accurate data on the underlying cause of death and contributory diseases, data generally best available through autopsy. More autopsies, more accurate autopsies, and more attention to proper completion of death certificates are needed.

The autopsy appears to be on the way to assuming an increasingly important role in patient care, continuing education, education of medical students and house staff, research in environmental pathology, and more fundamental aspects of disease. This trend needs to be nurtured. Not only pathologists but all physicians need to plan carefully to utilize autopsies to the fullest possible extent. Interest will continue to grow only if autopsies are performed or are closely supervised by highly motivated and experienced pathologists asking critical questions of current medical, scientific, and social concern. New, imaginative approaches are needed to develop the data necessary to address these questions.

Information concerning autopsy laws, regulations, rates, and practice was collected from 29 industrialized countries. In many countries, laws have been revised in recent years, introducing more restrictive rules, with consent required from the next-of-kin. With one exception (Finland), introduction of a requirement for consent was followed by a decline in the autopsy rate. Experiences in various countries are discussed. It is apparent that the problem of decreasing autopsy rates is an international one. Efforts to inform and educate the public about the benefits of autopsy are necessary, if the decision whether to perform autopsy is to remain their responsibility.

As viewed by pathology chairmen, the primary reasons for the decline in interest in the autopsy are: (1) a feeling among physicians that everything is known about the case; (2) poor education of medical students and clinical house staff concerning the importance of the autopsy, which carries over to the practitioner; and (3) lack of interest on the part of pathologists. Negative attitudes on the part of clinicians were seen as the primary factor that serves to inhibit enthusiasm for the autopsy on the part of pathology house staff. Lack of prompt and appropriate communication with the attending physician and uneven quality of prosectors are seen as major inhibitors to successful autopsy services. Chairmen of departments of pathology support an approximate doubling of the autopsy rate in their institutions (from 30% to 64%), although 42.5% of chairmen had not discussed their wishes concerning autopsy with the next of kin and only 42% regularly attend gross conference. These perceptions are remarkably similar to those provided by chairmen of departments of medicine and surgery as a part of a previous survey. On the basis of these inputs, several recommendations designed to improve the local emphasis on the autopsy service are provided.

Published studies encompassing more than 50,000 autopsies were assessed to determine the sensitivity and specificity of clinical diagnostics (the diagnostic process) in persons dying of 1 of 11 specific diseases during the period 1930 through 1977. The accuracy of clinical diagnostics, as reflected in these two determinations, appeared to improve over this period with respect to some of the diseases studied (rheumatic heart disease and leukemia), while for others it worsened (pulmonary tuberculosis, peritonitis, carcinoma of the lung, gastric carcinoma, and carcinoma of the liver and extrahepatic biliary tract) and for a significant number diagnostic accuracy seemed refractory to sustained change (pulmonary embolism, primary cirrhosis of the liver, gastric/peptic ulcer, and acute coronary thrombosis/myocardial infarction). The findings suggest a new way in which the autopsy can be used to monitor clinical diagnostics to identify possible sources of systematic weaknesses and provide data that can be used to approach the difficult subject of necessary fallibility.

A study of 2067 autopsies collected from 32 university and community hospitals of various sizes located throughout the United States showed the rate of discrepancies between premortem and postmortem diagnoses to be influenced by the type and size of hospital, the age and sex of the patient, and the disease responsible for the patient's death. Of equivocal or no influence were the length of the terminal hospitalization, the degree of clinical involvement in the case of the person responsible for establishing the discrepancy level, and the autopsy rate, at least as it applies to community hospitals.