The postmortem examination deserves its honored place in pathology – and medicine as a whole
I read this article this week and I wanted to share it because I feel very strongly about the value of pathology as a profession and the struggles the profession as a whole and individual pathologists face. I also believe that autopsy/necropsy is a vital part of what we do as pathologists. As a warning, this post includes discussion of death, disease, and dissection of dead bodies. None of it is graphic, but make the best choice for yourself. These are also my opinions, and I don't know everything, so do with that what you will. This is going to be a long one, so my thoughts are all under the cut…
Two disclaimers: The letter linked above is a response to a previous editorial. Both are written by pathologists. Both are clearly written from a place of deep caring about pathology and a drive to see more medical professionals take up this vital specialty. I have deliberately chosen to link the rebuttal letter and not the original editorial because I feel very strongly that the editorial makes some controversial (and, in my mind, harmful) assertions about autopsy and as such it should not be read without the response. But I do think that there is value in reading both. Secondly, I am writing this from my perspective as a veterinary pathology resident. There are differences between human and veterinary pathology in how we are trained, the role we play in the health of our patients and the public, and what our day to day jobs look like. With this in mind, some of the misconceptions about pathology discussed in these pieces resonated with me, which is why I wanted to share my thoughts, and hopefully get some of you thinking about the same things.
I’m going to pull some key points and quotes from the articles to discuss but again, I highly recommend reading both pieces for yourself. This might be a long one folks, so settle in.
”There is a lack of understanding of our specialty among medical school classmates and eventual colleagues”
I 100% agree. Most of my classmates have next to no idea what I do with my day, or why I care so much about pathology. And this is reflected in the submissions I receive as well. I believe that a large part of why I receive so many cases with insufficient history or inappropriate samples for what the clinician needs. While I recognize that there is not the time in veterinary school to teach every element of every specialty (and I also have a lot of thoughts about the way we currently approach veterinary education in general), vet students get a much more “real-life” experience of the clinical specialties than they do of pathology. The clinical year pathology rotations at the school where I trained and the one where I now work and teach focus entirely on necropsy which, while extremely valuable in its own right, is only a very small proportion of what pathologists do on a daily basis. There are many pathologists who don’t do any necropsies in their role, and we do a disservice to all students by not accurately demonstrating what a pathologist actually does. For veterinarians, necropsy and sample collection are the only skills an anatomic pathologist might use that may also be used in the clinic. But in the same way that I benefit from understanding how the surgery which produces the sample I analyse is performed, I believe there is benefit in clinicians knowing the basics of what happens to that sample when it reaches the lab to generate the report they read.
“Pathology? Don’t you want to be a real doctor?”
This one… oof. I have so many thoughts because I have heard this so many times myself. I’ve been planning a separate post on this point alone, and some of those thoughts are in the point above, but I want to emphasize that pathologists are real doctors. Pathologists are essential to medical practice. We are expert diagnosticians, and that skill is vital to how doctors in other specialties function.
“An autopsy is not healthcare in any form”
The women of the response do an excellent job of rebutting this point, but I would like to emphasize how deeply I disagree with this. Autopsy is closure for a family. Autopsy is the last chance of a person or an animal to tell the story of what happened to them. Autopsy is education, autopsy is our protection against malpractice, autopsy is progress and solutions and knowledge. On the veterinary side, the necropsy of one animal can save the rest of the herd. Imaging can do a lot, but it is no substitute for holding an organ in your hand and being able to look at any piece of it under the microscope. Only necropsy can give you that.
This statement also feeds directly into the misconception that pathologists are not doctors because we do not directly “fix” anything. Diagnosis is essential and more emphasis on how what we do as pathologists influences treatment decisions would help in improving the perception of pathology held by the rest of the medical and veterinary professions.
“All physicians perform a prolonged autopsy during their freshman medical school anatomy class”
Prosection to learn anatomy is not autopsy/necropsy. The function and approach is different, and this is not an accurate representation of either the practice and intention of a true autopsy. The prosections performed by junior med and vet students are there to teach anatomy – the process is drawn out, performed on preserved cadavers, and focusses on minute detail. Autopsy/necropsy is a medical examination. There are specific questions to answer, and the approach is designed to fill that purpose. A student who has only experienced anatomy prosection has no true understanding of autopsy. The do not understand the care, the intention, the science of a necropsy performed by a pathologist. And the suggestion that anatomy dissection could or should be the only experience our medical and veterinary students have of autopsy/necropsy will only lead the profession further from a true understanding of what it is pathologists do and why we value necropsy so highly.
“The dismembering nature of the practice”… “It is dirty, malodorous, and dangerous. It carries infection risks for pathologists”
This is a medical exam, not dismemberment. Aspects of necropsy can be dirty, malodorous, dangerous, and carry an infection risk, but so does surgery. So does palliative care. So does pediatric medicine and large animal medicine and laboratory work. As medical professionals we cannot shy away from what is unpleasant to the detriment of the dignity and care of our patients and the progress of our science and our professions. Necropsy is not always a pleasant process, and not everyone will want to perform them, that is true. However, I personally found surgery distasteful and unpleasant, that does not mean I think we should stop performing it. With the appropriate safety measures in place, necropsy does not pose a significantly greater risk to those performing it than any other medical procedure. However, this is a reason why physicians and veterinarians should be the ones performing autopsies/necropsies, not lay people or unsupervised technicians. Our training in the recognition of disease allows us the unique capacity to read a history and quickly identify those cases that pose a greater risk, and require more specific PPE or safety measures. SOPs can help, but no checklist or protocol can outweigh deep medical knowledge for assessing and mitigating the risks of exposure to cadavers.
“Those rare physicians who want to perform autopsies can undertake a forensics fellowship – but, again, why must they be pathologists?”
Pathologists have the depth of understanding of how disease progresses and how gross and histologic changes correlate which is vital for interpreting the nuance and inter-relationships of the various changes you can see in a single body. No other professional is adequately prepared to interpret these findings, and it devalues the practice of autopsy to imply that this is merely a sample collection and recording exercise.
Overall, I strongly believe that autopsy/necropsy has intrinsic value to the practice of medicine, and should continue to be a part of the training of not just pathologists, but every medical and veterinary student. The path to improving the perception of pathologists and the work we do is not through eliminating anything which makes people uncomfortable, but through providing better education so that the purpose of what we do, and how it helps and supports the practice of medicine in every specialty is better understood by our non-pathologist colleagues. Pathologists deserve respect, and denigrating what we do from inside the profession does nothing but detract from that. What we do is valuable. What we do is vital. And we need to help others see that.
Hello! Long-time listener, first-time caller here. This is a curiosity question about your academic career! (I am a PhD student, I know what it is like to Suffer.) So your residency program is the kind that has you pick up a PhD along the way, right? Is a PhD required to become a board-certified vet path? What happens if someone had a PhD in a relevant field BEFORE they got into vet school - would they have to do one again? This is something I'm trying to find the answer to for human medical residencies as well but the internet is remarkably unhelpful lol.
Hi! Welcome!
So, you're right, I am doing a PhD at the same time as I do residency, but programs like mine are actually the minority. There is no requirement for veterinary pathologists to have a PhD - just a veterinary degree and board certification. I have chosen to do the PhD (and picked the program I'm doing accordingly) because I have an interest in research and academia. The jobs I'm interested in for after residency in either academic institutions or industry research require or at least prefer a PhD, so here I am.
I can't speak with certainty for human medicine, but so far as I'm aware it's the same deal. Med school and residency are essential, the PhD is optional depending on what you want to do. But, if I have any human medical followers who can pitch in on this point, it would be much appreciated! Hope that helps, let me know if you have any more questions I can answer :)
So I’ve had a fair few questions recently about pathology and thought it might be helpful to do a few summary posts of the different things we pathologists do. Today I’m going to tell you about the what, how, why, and when of necropsy!
Warning: This post is going to be about dissecting deceased animals. I won’t use any graphic pictures but if the topic upsets you in any way, this may not be the post for you. Ready?
1) What is a necropsy?
Necropsy is the word we use for the post mortem (after death) examination of animals. It’s the equivalent of a human autopsy. Basically we get the body of a dead animal and we follow a specific dissection process aimed at inspecting every organ for abnormalities that may explain why the animal was sick and/or died.
2) How do you do a necropsy?
Everybody has a slightly different technique, but in the end they should reach the same result. This is a quick run down of how I approach it (this is where we’ll get into some discussion of actually dissecting bodies, so skip this if that makes you queasy).
1) External exam: The first step is to look at everything you can see without opening the animal. Same as a physical exam on a live animal, we assess the fur/feathers/scales, skin, eyes, ears, inside the mouth, claws, and so on. This is important because it can start you down the right track as to what you’re going to find inside. For example, a cat that has been hit by a car usually has shredded claws, because they try to grab onto the road at the point of impact. Or if you find blisters in the mouth and between the toes of a pig you might want to quickly get on the phone with the state vet because you suspect foot and mouth disease! We also take note of identifying features of the animal (colour, brands, microchip number, ear tags etc) so that the findings can be matched to the right animal (which can be contentious in insurance or legal cases).
2) Opening the animal: So now I’m ready to start cutting. How you position the animal to start depends a bit on the species, but for your average mammal you’ll lay them on one side. I then get the legs, skin, muscles, and ribs out of the way so that the abdomen and thorax are open for inspection.
3) Stop and look for a minute: Before we take anything out it’s important to take a moment to look at how things are sitting. Are all the organs in the right place? What colour are they? Is there any fluid there shouldn’t be?
4) Examine the organs: Now that we’ve taken note of how things were, we can start taking things out and getting a more detailed look at them. Every organ gets its moment in the spotlight. Tubular organs get opened so we can look at the inside, and parenchymous (solid) organs get sliced into so we can see anything going on in the middle of them. And while we’re doing this, we take a piece of everything. Some things we’ll keep fresh for microbiological or toxicologial testing - lung, liver, spleen, and kidney usually, occasionally brain if it’s indicated - and everything else goes in formalin to preserve it for looking at under the microscope later.
5) Tidying up: After we’ve looked at everything, it’s time to clean up. This depends on what the owner wanted. Animals are often sent off for cremation after this process, but if the owner wants to animal back we can do what is called a “cosmetic necropsy”. When we do this we just get into the animal through one incision along its belly, which we stitch back up when we’re done. Overall, we try to be as respectful as possible, and if you do have concerns about the animal you are submitting for examination, you should talk to your pathologist! We’re happy to answer questions and will try to accommodate your needs during the process.
6) Writing a report: Every necropsy performed should be followed by a report lisitng everything we saw while we did it. This is a legal document which includes everything that was abnormal, everything that was normal, and anything needed to identify the animal.
3) So wait... why are we doing all of this?
For a lot of people, it can be hard to understand why we are still looking into what was wrong with an animal after it has died. And I get that, we’re a bit past the point of helping that animal once it reaches the necropsy floor, so who cares?
Well for one, in a significant number of cases the animal dies without us knowing why, and that makes it hard to find closure. Maybe your pet died suddenly, or it was being treated for something but died anyway. With a necropsy we can either give you a solid answer as to what caused your animal to pass away (maybe there was a tumor you didn’t know about, or a clot) or we can tell you that there’s no evidence of anything that you could have helped or prevented. That knowledge and reassurance can help owners process the death of their animal, and I’ve seen it make a big difference.
Secondly, if there are other animals involved or at risk, we can find out how to help them! This reason is most often applied to production animals where we can figure out herd health problems, but it can apply to pets from a household with other animals as well. If your dog dies from getting into something toxic, it’s good to know that happened so you can remove the poison and possibly save your other dogs from the same fate. Or if there’s an infectious disease moving through your herd of cattle, now you know how to treat or what to vaccinate against. It may be too late for the animal on my table, but that animal might still be able to help the others around it.
Thirdly, that information could help save animals you don’t even know. The information we find at necropsy can educate the vet who was treating it, students present for the examination, and the veterinary community at large. Maybe your animal presented unusually for a known disease, so your vet didn’t recognise what was happening. That’s sad, but vets are human too and can’t know everything. But now that they know what killed your pet, they’ll know to check for that in the next patient with the same presentation. Veterinary students see and participate in necropsy at school so that they can know what lesions look like before going out into practice. The more they can see, the more knowledge they are equipped with before your sick pet is in front of them. And maybe your animal had something wrong with it that nobody knew happened. If we can see that at necropsy we can publish information to teach vets all over the world that this can happen and we need to find out how to fix it.
If you’re still reading, thanks! I hope this has taught you a little something about the necropsy process. If you have any questions do feel free to ask, I love pathology and would like nothing more than to help people understand it and remove some of the suspicion that surrounds what we do. Next week I’ll be doing “What are you looking at down that microscope” OR what is histology and why do we do it? So if there’s anything you want to know about microscopic tissue examination let me know!
Anatomic and Clinical Pathology - What’s the difference?
Pathology Saturday’s with Lizze part 3 comes to you on... Sunday. Sorry guys, a side effect of residency in any specialty is that they kind of own you, so when I got a call at 3am on Saturday morning I had to go, and that sleep deprivation interfered with my writing plans.
Today’s topic is a question I get every time I talk about veterinary pathology. To be honest, I didn’t even really understand the difference myself until I started to think about doing a pathology residency.
Before we start, make sure you check out the first two Pathology Saturday posts on necropsy and histology. Ok, now we’re ready!
1) You have two seconds to explain the difference - go!
My rapid fire explanation is this - if you sample it with a needle it’s clinical, if you sample it with a knife it’s anatomic.
2) Ummm... ok, what does that actually mean?
The difference between the two specialties comes down to the types of things we look at and the methodology we use to come to a diagnosis. This affects not just what we do, but where we work and how quickly we can give you an answer.
3) What does an anatomic pathologist do?
Anatomic pathology covers two main diagnostic methodologies I’ve already written introductory posts on - necropsy and histology. Those posts are linked about but the quick summary is this:
Necropsy - dissection of a cadaver and examination of the tissues with the naked eye to look for lesions (changes associated with disease or injury) and collect samples for bacteriology, toxicology, and of course, histology.
Histology - microscopic examination of slides made from thinly sliced tissue specimens collected at necropsy or surgery (biopsies). With this we can look at the types of cells in the tissue and how those cells fit together (the architecture).
Structure is an important feature assessed in anatomic pathology, so the techniques we use maintain that. As opposed to...
4) What does a clinical pathologist do?
Clinical pathology includes interpretation of blood tests (biochemistry and the complete blood count), urine tests, and cytology. Now I’m not an expert on any of this but I’ll quickly explain cytology because it’s where the two specialties tend to get confused.
Cytology - microscopic examination of slides made with cells where the tissue architecture is not maintained or assessable. These cells are collected through aspiration (sticking a needle in something), scraping, or pressing someting against the slide. You get a random selection of whatever cells can be picked up by the method that you choose. You can also look at fluids (which may or may not contain cells) this way.
5) What else is different?
Residency - from my understanding, many anatomic pathology residencies will take you straight out of vet school (how I got into this). Clinical pathology residencies tend to prefer that you have experience in clinical practice, and often like you to have completed a rotating clinical internship as well. In some places a pathology residency will cover a bit of both specialty though, so things can get complicated!
Where are things done? - Parts of each specialty can be done by a general practice vet in clinic, but obviously there are added benefits to consulting a specialist. A lot of GP vets will do some of their own clinical pathology - in-house blood analysers are becoming more common, where you can get point of care results for quick analysis, and most clinics have a microscope so they can take a quick look at cytology to make the decision to ask a specialist or not. GP vets can also do their own necropsies, which is a good way to reduce costs. However GP clinics are not set up to do their own histology - that requires a lot of processing that isn’t plausible within a GP clinic, and vets aren’t routinely trained in much histopathological interpretation.
I have heard of specialist clinics with in-house clinical pathologists for convenient consultation by other specialists. This allows them to work closely with internal medicine over blood and urine results, and cytology of fluid pulled from abomens and chests; and both surgeons and medics can benefit from other cytological examination. Anatomic pathologists, largely because of the need for histology processing equipment, tend to be more affiliated with diagnostic labs, although there are many of these located close to or associated with teaching hospitals.
So that’s the basics of the difference for you guys! Any clinical pathologists out there, feel free to chime in and correct me because I obviously don’t have a lot of experience with the specifics of becoming and being a clinical pathologist.
There’s a list of topics I’m thinking about at the bottom of the histology post if people are interested in placing votes, otherwise next weekend I’ll just pick what takes my fancy :)
