Autopsy has greatly facilitated the evolution of clinical medicine, and as the foundation of pathology, its contribution to clinical medicine is unique. What if there were no autopsies? Dr. Lundberg, a pathologist and former editor of JAMA, once said: “Medicine without the autopsy would not be worth being part of”.1 Autopsy is the last resort for diagnosing disease and identifying causes of death; moreover, it is an eternal source of knowledge of novel diseases that is not available in the textbooks. Hill and Anderson2 reported that 87 diseases in 10 categories were identified by autopsy from 1950 to 1990. More recent examples include the discovery of severe acute respiratory syndrome (SARS) epidemic in 2003 and the avian flu epidemic in 2006. Although physicians understood the clinical course of the two diseases, it is autopsy that provides the critical information about the pathological changes of these diseases. Another classic illustration of the role of autopsy involves the pathology of coronary artery disease: it was only 140 years after the first description of coronary heart disease in 1772, did autopsy reveal that atherosclerotic embolization in the coronary arteries is the main cause of the condition.2 Many believe that extensive practice of autopsies is important for clinical medicine, medical education, epidemiology, and public health, and this is especially true in China, because China has the world’s largest population, and presumably the world largest disease spectrum to discover new diseases. Today even when various novel diagnostic techniques are being invented with increasing rapidity, autopsy is still important for a comprehensive understanding of diseases and in some cases, for a final diagnosis of patients.
Does modern medicine still need autopsy? The answer is affirmative.3-8 Unfortunately, the autopsy rate has been declining worldwide over the last 40 years,9,10 and the situation in China is even more distressing. Over the past two decades, the autopsy rate (autopsy case/inpatient deaths) in most large teaching hospitals (those with more than 1500 beds) in China was less than 1%; many hospitals did not perform even a single autopsy for years. This trend is worrisome not only for pathologists, but also for clinicians and relevant policy-makers. This article reviews the past and present of autopsy in China and analyzes the main reasons for the decreasing autopsy rate.
HISTORY OF AUTOPSY IN CHINA
It is generally believed that China started its modern anatomy and autopsy practices only after the introduction of western medicine, despite the fact that the world’s first forensic monograph, Xi Yuan Ji Lu, or Collected Cases of Injustice Rectified, was written by a Chinese named SONG Ci, who lived in the Southern Song Dynasty (1247; Figure 1). The book has been translated into English, German, Japanese, French, Dutch, Russian, and many other languages; it introduces the postmortem examination which was performed mainly by observation rather than autopsy; so SONG Ci is much a coroner rather than a pathologist (Figure 2). Although anatomy and pathology were introduced to China in around 1840, autopsy was prohibited in China until 1912. In 1904, the government of the late Qing Dynasty prohibited autopsy as a course for medical students in its Regulations for Higher Education, but allowed teaching with a human anatomical model. On November 22, 1913, the Beiyang administration of that time officially permitted autopsies in the President Proclamation and Orders of Ministry of Internal Affairs. Nine days earlier, on November 13, 1913, China performed the first public autopsy in its history at the Jiangsu Provincial Medical College, with more than 100 witnesses, including scholars from China and abroad and government officials (Figure 3). Since then autopsy has been used in teaching and medical practice in China.
Pathology as an independent discipline has developed very slowly in China. In 1912, the Ministry of Education, for the first time in Chinese history, officially listed 48 courses for medical institutions, including pathology. Peking Union Medical College established the first pathology department in China in 1920; the first dean was American pathologist Mr. RG Mills. In 1927, Prof. GU Jing-yan, who returned to China after studying in Germany, established the pathology department in the Shanghai Medical School. China had less than 50 pathologists before 1950, and only a few teaching hospitals performed autopsies; therefore, the autopsy data before 1950 are not available for analysis. Even so, autopsy has played a very important role in Chinese medical history. For instance, in the 1930s the “Yangtze Fever” epidemic, with unknown origin and rampaging the Yangtze valley, was proven to be Japanese schistosomiasis by autopsy. According to the findings by autopsy, researchers found that infectious diseases were the main cause of death in China during the period of 1930-1960. Since 1950, pathology has developed rapidly in China, and by 2008 more than 10 000 hospitals in China have established pathology departments and about 22 000 people are involved in pathology-related work. This review has been approved by the Medical Ethics Committee of Changhai Hospital, Second Military Medical University, Shanghai, China.
AUTOPSY RATES AND RATES OF MISDIAGNOSIS FOUND BY AUTOPSY
Autopsy rates in eight large hospitals in five regions of China during 1951-1990
Since 1950, autopsy after the death of hospital patients has been performed with increasing rapidity in China. We retrieved the pathology literature published during 1954-2008 and surveyed the representative large teaching hospitals. The highest autopsy rates were found between 1950 and 1960; they decreased rapidly during the 1970’s (Table 1) and reached their lowest point after 1990; almost no autopsies have been performed since 2000 in most hospitals surveyed.
From 1998 to 2008, the autopsy rates in five representative teaching hospitals in four different cities were as follows: Peking Union Hospital (Beijing), 2.04% (97/4752); Changhai Hospital (Shanghai), 0.35% (17/4832); Southern Hospital (Guangzhou), 0.21% (8/3818); Xijing Hospital (Xi’an), 0.50% (23/4578); and Changzheng Hospital (Shanghai), 0.04% (2/4654). In addition to these five hospitals, we also obtained the data of 20 other large teaching hospitals and found that all of them had an autopsy rate less than 1%. Some hospitals did not perform a single autopsy for years. Since 2002, there have been a few medico-legal autopsy cases. Table 2 shows the cases of medico-legal autopsy in four cities during 2002-2008.
Rate of misdiagnosis according to autopsy results in fifteen large hospitals during 1950-1999
Studies have shown that autopsies confirm the diagnoses in 15%-40% of all dead in hospitals.6,10-17 The rapid development of modern medical technology has failed to reduce the clinical misdiagnosis due to an ever-changing disease spectrum; therefore, autopsy remains vitally important for confirming diagnoses and for correcting diagnostic mistakes.18Table 3 shows the high rate of misdiagnoses as assessed by autopsy in 15 large hospitals in China. The misdiagnosis rate for medico-legal autopsy cases is much higher than that for other autopsy case.
AUTOPSY-BASED CLINICAL RESEARCH
Chinese authors have published very few papers about autopsy-based research in recent years owing to the extremely low autopsy rate. We only retrieved 63 papers reporting the results of autopsy from 8409 papers published during 2000-2008 in five top Chinese medical journals sponsored by the Chinese Medical Association, including 9 from 3974 papers in the National Medical Journal of China, 11 from 1171 papers in the Chinese Journal of Internal Medicine, 34 from 950 papers in the Chinese Journal of Pathology, 1 from 1177 papers in the Chinese Journal of Oncology, and 8 from 1177 papers in the Chinese Journal of Pediatrics. Only 16 of 2225 papers submitted to six annual meetings (2004-2009) of the Chinese Pathological Association were found based on autopsy results.
China has not held a single conference focusing on autopsy since 1950. On September 27, 1997, eight pathologists from Beijing were called together by the National Medical Journal of China for a seminar focusing on The importance of autopsy under the condition of modern medical condition. From November 21 to 24, 2008, we hosted the first conference on medico-legal autopsy in China’s history, and this article, to our knowledge, is the first paper written in English to focus on autopsy in China.
REGULATIONS AND LAWS REGRADING AUTOPSY IN CHINA
It was not until 1950’s did China trained the first group of pathologists, and since then the medical colleges and hospitals have begun to establish their pathology departments. To promote autopsies in China, the Chinese government issued Regulations for Anatomy in 1957. And as a consequence, the autopsy rate was high at teaching hospitals from 1950 to 1960, but this high autopsy rate did not last very long. In the 1970’s, the autopsy rate decreased rapidly, and in 1979 the Ministry of Health issued a revised Regulations for Anatomy, which stated that autopsy was required for (1) deaths of unknown causes, (2) deaths with potential scientific values, (3) deaths where permission for autopsy was given by either legal will or the relatives of the dead, and (4) deaths due to poisoning or fulminating infectious diseases; in cases (1) and (2), consent from the relatives of the dead was needed before autopsies. Nevertheless, this new version of the regulations failed to reverse the decline in the autopsy rate due to various reasons. In 1987, the State Council of China issued The Measures on the Handling of Medical Accidents, which requires autopsies for deaths where the cause of death was disputed. However, in most cases the disputes were solved through negotiation rather than autopsy, largely due to the limited autopsy knowledge by relatives of the dead. In September 2002, the State Counsel revised the old version and issued The Regulation on the Handling of Medical Accidents, which states that autopsy is required for inpatient deaths when the cause of death is disputed; both the hospitals and the relatives have the right to apply for an autopsy. If one side refuses the autopsy application made by another, it must take the full responsibility. Consequently, medical accident-related autopsies have increased since September 2002, especially in the highly economically and culturally developed cities. But even in such circumstances, the absolute number of autopsy cases remains very low as shown in Table 2.
In fact, early in 1989, China began to grade its hospitals as levels I, II, and III. There is a criterion aimed at promoting autopsy in the grading: a level II hospital must have a minimal autopsy rate of 10% and a level III hospital a minimal rate of 15%. Unfortunately, to our knowledge, not even a single hospital can meet this criterion when applying for the grading, so the autopsy criterion is not really considered during the grading.
REASONS FOR THE DECREASE IN THE AUTOPSY RATE
The decreasing autopsy rate has become a worldwide problem.9-12,19-21 The reasons for this decrease vary in different countries during different time periods. Many authors have analyzed the reasons for reduced autopsy rates and their negative impact on the progress of medical science.8,11,13,15,18-21 According to the pathologists who attended the seminar sponsored by the National Medical Journal of China in 1997, there were multiple reasons for the decreased autopsy rate in China. After a thorough literature review and investigation (private communication), we found that the reasons for the decreased autopsy rates in China were similar to those in other countries, but prominent differences exist owing to different social institutions, culture, economy, and social values. We summarize the reasons for the declined autopsy rate in China as below.
Hospital administrators and health administration authorities neglect autopsy
Among the approximately 1000 large hospitals in China, it is hard to find a hospital president or other administrators who have shown any concern about the autopsy cases performed in their hospitals. These hospital administrators do not consider autopsy as an important criterion for quality control of their health service and do not appreciate the value of autopsies. In China, the hospital presidents are in charge of the hospitals and administrative intervention is often more effective than any other measures. Unfortunately, to date, no such interventions have been implemented.
Clinicians are not motivated to order autopsies
Since the hospital presidents and other authorities do not see autopsies as important, clinicians seldom make efforts to ensure a needed autopsy performed. In addition, clinicians have to persuade the relatives to give permission for an autopsy, and most importantly, clinicians worry about possible disputes arising from a disagreement between the autopsy results and the clinical diagnosis. Currently, clinicians in Chinese hospitals, especially the young ones, have almost lost the concept of performing autopsies.
Helpless pathologists: the spirit is willing, but the flesh is weak
Pathology has always played an irreplaceable role in clinical medicine. Generally pathologists are highly respected in most countries, but not in China. In Chinese hospitals, the departments are divided into clinical departments and adjuvant departments; unfortunately, pathology department falls into the latter category. This groundless and aimless categorization has resulted in a decline in pathological departments in Chinese hospitals. In addition, medical graduates are reluctant to work in the pathology departments, leading to a shortage of pathological professionals and a burdensome workload for the existing pathologists. In an extreme case, a hospital with more than 20 000 clinical specimens annually had fewer than ten pathologists. Without autopsy, the pathologists are given very little attention; they may have made efforts to improve the autopsy rate, but their efforts were in vain without the support of the hospital presidents. The autopsy rooms have been closed in some hospitals, and many young pathologists have never performed an autopsy. However, we believe that if autopsy is given enough attention by all the parties involved, the Chinese pathologists would be glad to perform every autopsy, even when they already have a heavy workload.
Issuing and implementing relevant regulations and laws
Some regulations and laws have proven effective in promoting the autopsy rate in some countries.8 The implementation of regulations and laws is more important than issuing the laws and regulations in China. The Ministry of Health of China clearly stipulates the preferred autopsy rates for Grade II and III hospitals, but the requirement is abolished when not a single hospital can meet the standard. If regulations and laws are not effectively implemented, they only make the situation worse. If the importance of autopsy is fully understood by all the parties involved, and if the autopsy rate is taken as an operative requirement, the hospital president and relevant administrators will take concrete measures to improve the autopsy rate.
Attitudes of relatives and local customs have hampered the performance of autopsies
All autopsies in China need the consent of the relatives of the dead. However, this should not be the main cause for the reduced autopsy rate. When there is no communication between doctors and relatives after the death of patients, we are not expecting the relatives to initiate a request for an autopsy. The relatives of the dead, like most of the people in China, know little about the significance of autopsy. In some underdeveloped areas in China, there is a custom that people must die at home, so the patients are usually brought home when their relatives finally think it should be done. Education of the public on autopsy is urgently needed in China. The high autopsy rate in the 1950’s and 1960’s in China was primarily due to the efforts by the hospitals and government to educate the public and promote autopsies. Of course, consent is hard to obtain from relatives who come from areas with different cultures and religions, but the key is always in the hands of clinicians; this is also true in other parts of the world.4,6,8,20,21
There are still other reasons for the reduced autopsy rate in China. Currently, hospitals in China have very little financial support for autopsy, not to mention an expansion of pathology departments, and the out-dated autopsy equipments could have been diverted for other uses. The low quality of the autopsies might be another reason that clinicians see little value in autopsies; on the other hand, young clinicians have very little chance to perform autopsy, which makes it harder to improve the autopsy quality; thus, there is a vicious circle. If each autopsy case is seriously taken as a valuable chance for the scientific practice of clinical medicine, the clinicians will undoubtedly see its benefits.
The important implication of autopsy after the death of inpatients needs no further description. However, a worldwide reduction in autopsy rate has greatly worried the pathologists for the past several decades. Autopsy as a final resort for diagnosis and an import way to discover novel disease deserves serious attention, which is especially true for a country like China, who has the largest population in the world. China can make greater contribution to medical science if effective measures are taken to promote autopsy-based research. We hope this article will raise awareness among all the relevant parties and contribute to the improvement of autopsy in China.
We thank Prof. CHEN Jie (Department of Pathology, Peking Union Hospital, Beijing), Prof. ZHENG Jie (Department of Pathology, Peking University, Beijing), Prof. DING Yan-qing (Department of Pathology, Southern Hospital, Guangzhou), Prof. ZHOU Ren (Department of Pathology, Medical College of Zhejiang University, Hangzhou), Prof. LI Bing (Changzheng Hospital, Shanghai), and Prof. CHENG Hong (Department of Pathology, Xijing Hospital, Xi’an) for providing the data of their hospitals. We also thank Prof. TAN Dong-feng, Department of Pathology, University of Texas, USA for his suggestions on the manuscript.
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