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• Comment on: 'The value of autopsies in the era of high-tech medicine: discrepant findings persist." Kuijpers C.C.H.J. et al. J Clin Pathol 2014;67:512-519 doi:10.1136/jclinpath-2013-202122
  Simone L. Van Es
  Published on: 18 April 2016

• Published on: 18 April 2016

  Comment on: 'The value of autopsies in the era of high-tech medicine: discrepant findings persist." Kuijpers C.C.H.J. et al. J Clin Pathol 2014;67:512-519 doi:10.1136/jclinpath-2013-202122

  • Simone L. Van Es, Anatomical Pathologist and Lecturer in Pathology

  To the Editor: Without doubt the hospital-based autopsy is an effective quality assurance and learning tool. The study by Kuijpers et al. supports this.[1] However, autopsy is a time-consuming and expensive procedure which may sometimes cause distress to the deceased patient's family and be associated with complex consent issues. It is therefore important to ask how far reaching, beyond the pathologist and the referring cli...

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  To the Editor: Without doubt the hospital-based autopsy is an effective quality assurance and learning tool. The study by Kuijpers et al. supports this.[1] However, autopsy is a time-consuming and expensive procedure which may sometimes cause distress to the deceased patient's family and be associated with complex consent issues. It is therefore important to ask how far reaching, beyond the pathologist and the referring clinician, is the learning impact of each individual autopsy?

  The clinician requesting the autopsy is interested in the bullet- point preliminary summary (based on the macroscopic findings) that is signed out immediately. But how often is the final detailed multi-page report followed up? Autopsies and the associated laboratory tissue- processing usually do not take priority in a busy diagnostic department. Final reports may not be verified for some time after the procedure, decreasing their learning impact.

  Frequency of minor diagnostic errors, as measured by the autopsy gold standard, is increasing over time.[1] Improper use of imaging investigations is contributing significantly to incorrect pre-mortem diagnosis.[1] Could it be that the main problem is that there has been a huge increase in the number of diagnostic investigations that can be requested during life? More investigations at our fingertips do not necessarily make things better for the doctor, or for the patient.[1] How do we learn how to optimally use these investigations to avoid misdiagnosis or alternatively to optimally learn from the inappropriate use of past investigations, so that errors are not repeated?

  Some of the current issues with use of diagnostic investigations are as follows: 1. Understanding the tests: a. Wrong test selected for the situation - whether it be imaging or diagnostic pathology. This results in false positives or false negatives; b. Sensitivity, specificity and positive/negative predictive value - these parameters of a particular imaging modality or pathology test may not be appreciated. Acting on the false result whether it is negative or positive may have significant detrimental clinical impact; c. With complex histopathology or imaging investigations, are the nuances in the body of the report skipped or overlooked by the treating clinician? 2. Communication: a. With immensely busy clinical loads, how often is the suitability of the investigation or the unexpected final result discussed with the radiologist or pathologist? In other words, how often do we practice in a vacuum because of time constraints? 3. Clinico-pathological and radio-pathological correlation: a. Were the radiologist or pathologist given any clinical information, and if not did they seek such information before reporting?

  Obviously selection and interpretation of diagnostic tests is often not clear-cut in the real world. Furthermore, with increasing numbers and complexity of diagnostic tests come increasing workloads for pathologists and radiologists. There is increased expectation from both patients and referring clinicians. Faced sometimes with extraordinary numbers of cases to report each day, the pathologist may fail to look for or may miss a vital component of the history that was provided to them by the radiologist or clinician. This is easy to do in an electronic era where most reports and referrals are scanned and it takes time to search. There will also always be cases where only a proportion of slides or images were viewed before issuing a report. Errors are part of the human condition. The key is to learn from errors and to not repeat them.

  In summary, autopsy has always been an excellent tool for quality assessment in diagnostic accuracy. But is it a teaching and quality assurance procedure that is time and cost-effective, with results that are easy to disseminate with maximum learning benefit? Focus on development and delivery of high impact and time-efficient continuing education modules (particularly online) regarding quality assurance errors and diagnostic and investigative medicine has already been demonstrated to be of value,[2] so such modules may represent an alternative solution to these issues.

  References 1. Kuijpers C.C.H.J., Fronczek J., van de Goot F.R.W., et al. J Clin Pathol 2014;67:512-519 doi:10.1136/jclinpath-2013-202122 2. Ritchie A., Jureidini E. and Kumar R.K. Educating Junior Doctors to Reduce Requests for Laboratory Investigations: Opportunities and Challenges. Med.Sci.Educ. 2014;24:161-163 DOI 10.1007/s40670-014-0041-2

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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