|Year : 2015 | Volume
| Issue : 2 | Page : 39-40
Reviving hospital autopsy in Nigeria: An urgent call for action
Dauda Eneyamire Suleiman
Department of Pathology and Morbid Anatomy, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Web Publication||2-Mar-2016|
Dauda Eneyamire Suleiman
Department of Pathology and Morbid Anatomy, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Suleiman DE. Reviving hospital autopsy in Nigeria: An urgent call for action. Ann Nigerian Med 2015;9:39-40
It is no longer news that in most tertiary health institutions in Nigeria, hospital/clinical autopsy is for all intents and purposes, dead. What is most shocking, however, is that it appears that absolutely nothing is being done about it by relevant stakeholders. If this unpalatable situation is allowed to continue, a time will come when even the pathologist who possess the necessary skill to perform autopsies will become extinct, leaving the future practice of medicine blind to the many adverse consequences of clinical actions or omissions.  The importance of autopsies, especially hospital autopsies are well-documented. In addition to determining the cause of death, the autopsy remains a veritable tool for elucidating the changing spectrum of diseases; it allows confirmation, classification, and correction of antemortem diagnosis as well as identification of new and reemerging diseases. Beyond these, autopsy can serve as a quality assurance tool to assess the standards of clinical practice and can help grieving families in the psychological healing process by providing clearer explanations on the processes that led to the death of their loved ones. The discovery of hitherto unrecognized genetic diseases enable family counseling and prevention of serious consequences in family members. , Finally, the educational benefits of clinical autopsy are second to none; it provides a very unique learning opportunity where all interested parties, including the pathologist who performed the autopsy, to gain new insights into the disease process that led to the demise of the deceased.
The decline (or lack of) clinical autopsies is by no means limited to Nigeria. Hospital autopsy rates have been falling in the UK and worldwide for over half a century and account for a small minority of all autopsies in the UK with some recent studies quoting autopsy rates of less than 10% for UK teaching hospitals and less than 5% elsewhere.  It is worth noting however, that despite the availability of newer "high tech" diagnostic techniques, studies comparing the accuracy of clinical diagnosis in different medical eras have shown no decline of error in clinical diagnoses. An editorial in the "Journal of the American Medical Association" observed that "there is still a giant gap between what high-tech diagnostic medicine does in practice and what it does in real life circumstances."  In a study that focused on myocardial infarction (MI) as a cause of death, significant errors of omission and commission were found with a sizable number of deaths that was ascribed to MI turning out to be something other than MI; similarly, a significant number of non-MIs were actually MIs.  Similarly, a large meta-analysis suggested that approximately one-third of death certificates were incorrect and that half of the autopsies performed produced findings that were not suspected before the person died.  Discordance rates between clinical and autopsy diagnoses remain very high with various studies in the UK, US, and the Americas quoting rates ranging from 20-45%! , Considering the relative dearth of these so-called high-tech diagnostics, it may not be totally erroneous to conclude that the discordance rates may be much higher in our setting. It is only via clinical autopsy that such discordance can be corrected and clinical lessons learnt. Moreover, many of these new technologies have potential pitfalls in their interpretation; therefore, the autopsy remains the "gold standard" for validating new and emerging technologies. 
Various complex reasons have been adduced for the decline in autopsies ranging from sociocultural/religious objections to public aversion to the procedure. However, as far as the hospital autopsy is concerned, there is perhaps only one simple reason - that the clinicians are not requesting for autopsies. The reasons offered by the clinicians for this include the belief that the autopsy is unlikely to add anything new to the clinical diagnosis, as well as difficulties in persuading a grieving family member to agree to an autopsy.
In reviving the hospital autopsy in our setting, all concerned parties must embrace the autopsy and recognize it as a useful tool in the bid to improve the quality of care. It would seem far-fetched and perhaps foolhardy to suggest that hospital autopsies be made compulsory for all deaths within the hospital. A more realistic starting point however, is to make it compulsory in those select cases in which a clinical diagnosis has not been arrived at prior to death or in cases where the sudden deterioration in clinical condition cannot be entirely explained by the working diagnosis. The attending clinician must make it a duty to initiate discussions on autopsy after informing the deceased person's relatives of their loved one's demise. This would undoubtedly require specific communication skills, which most physicians, admittedly do not possess. Training of doctors in this regard may assist in overcoming this difficulty. A national policy on hospital autopsies in all tertiary health centers in Nigeria would provide the necessary administrative backing and provide a clear direction to all stakeholders. The suggestion that autopsy rates should be part of the accreditation parameters of teaching hospitals might be worth looking into.
The possibility of malpractice claims may be a cause of concern for the clinicians but it appears that autopsy, more often than not, helps the clinician. A study found no reported case of malpractice action initiated solely on the basis of unexpected diagnostic errors or complications detected at autopsy.  Another study assessing the role of autopsy information in malpractice cases found that defendant physicians usually were exonerated, and that observance of the standard of care was deemed more important in determining medical negligence than the accuracy of clinical diagnosis. 
On the whole, it appears that medical practice has significant gains to reap from the resuscitation of autopsy. It can be considered as a unique gift from the dead to the living and it is an avenue that ensures that hospital mistakes are not buried but used to improve the quality of care. With the relegation of the autopsy to the background, it would be apt to conclude with the ever so valid comment by Giovanni Battista Morgagni: "Physicians who have done or seen many autopsies have learned at least to mistrust their diagnosis; the others who don't confront themselves with the often discouraging findings of autopsies, live in the clouds of a vain illusion."
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