I’ve been spending an inordinate amount of time and effort working recently, so perhaps I should mention the sort of thing I do.

I am a pathologist. Queue the sharp intake of breath. I can also feel a morbid curiosity taking hold. It’s not for everyone, and to be honest, very few people understand what we do. Even other doctors have to have the specialty explained, and that we don’t just deal with bodies or operate a machine that tells us all the answers.

Post mortems are the (dead) elephant in the room. The reality is they are only a small part of the job for most hospital pathologists. It’s a different story for forensic pathologists who are engaged exclusively in autopsy work. Histopathologists only elect to do autopsies on top of their NHS work (at least that’s how it works in the UK). The autopsy work I perform is for the Coroner, and involves the investigation of non-suspicious deaths in the community and in hospital. As soon as there’s a hint of third-party involvement or anything untoward, the case becomes a matter for forensics.

Mortuaries aren’t in dark and dingy basements. For the most part, modern mortuaries are brightly lit with white walls and stainless steel tables and benches. They’re probably one of the cleanest rooms you’ll see, and have to be meticulously cleaned at the end of every work day. Any location handling human tissue from deceased individuals is strictly regulated by the Human Tissue Authority (HTA) which came about in the wake of several high profile organ scandals in the UK. Any tissue removed from a body must be tracked and only used for specific purposes for which there is consent. Coronial post mortems are a little different as the Coroner can authorise the removal and storage of tissue if it pertains to the cause of death, until the case is closed. After this point it’s up to the next of kin to decide if they would like the tissue to be retained for education and research, disposed of, or returned to the body (depending on funeral arrangements and timings).

Post mortems have provided a vital tool for advancing medical science for thousands of years, and can also offer closure and an answer to grieving families. Given their important role in the foundation of medicine, it is slightly alarming to see the steep decline in numbers in recent years. Plenty of coronial post mortems are performed, but very few consented autopsies are done in the pursuit of enhancing understanding of a disease process or refining a cause of death (we have had one to two cases a year for the last few years). This is a stark contrast to thirty years ago when the practice was commonplace.

The decline in consented autopsy is multifactorial. Imaging techniques (CT, MRI, ultrasound etc) have become much better and diagnostic confidence has increased, there has been increased scrutiny of pathology following several organ retention scandals, and the health service is so much busier than in the past. Pathologists don’t have a lot of spare time, and other doctors don’t have time to come to observe and discuss findings.

I have mentioned organ retention scandals a few times, but the most high prolife case involved the Dutch pathologist Dick van Velzen (who has been subsequently struck off the General Medical Council register and cannot practice medicine in the UK any longer). Dick van Velzen was working as a paediatric and perinatal pathologist (a sub-specialty of histopathology) performing autopsies on babies and children, and had been retaining organs without consent. Many of the organs were stored in “pots”, glass containers filled with formalin, a method used for over a hundred years to store pathological specimens. After van Velzen left the UK he practiced for a short time in Canada and was found to have stored further retained organs in a storage locker with his personal effects.

The issues only came to light after the death of Samantha Rickard, whose mother Helen Rickard requested Samantha’s medical records after hearing about ncreased mortality rates for paediatric heart surgery at Bristol Royal Infirmary (BRI). Within the records she found a letter stating that Samantha’s heart had been retained, which she was never informed of. She then set out to get to the bottom of things and to support other families affected by unauthorised and illegal organ retention. Around 850 infants had organs inappropriately retained, culminating in a public inquiry in 1999, and the Human Tissue Act of 2004. This led to the establishment of the Human Tissue Authority in an attempt to regain public confidence in the medical establishment, and to try and prevent such a heartbreaking tragedy ever occuring again.

As far as the day to day practice of autopsy goes, these are undertaken by pathologists who have either forensic training or, if a histopathologist, the Certificate of Higher Autopsy Training (CHAT). Technically any doctor instructed by the Coroner can perform an autopsy, but in reality pathologists are trained specifically for this and are the only doctors who carry out post mortems in the UK.

How do you become a pathologist? The minimum amount of time between leaving school and becoming a consultant pathologist is twelve years. That’s five years medical school, two years foundation training, and a minimum of five years specialist training. Once you’re in the training programme there is one hard exam (FRCPath Part 1), and one eye-gougingly expensive and difficult one (FRCPath Part 2), plus an additional autopsy exam (CHAT). Not everyone who does pathology does autopsies though. Autopsy is only mandatory for the first two years of training, during which you need to perform 20 autopsies per year. After that the expectation is roughly 20 autopsies a year until you finish training if you intend to keep up the practice. Like all branches of medicine, maintaining competence is essential and that involves getting plenty of experience.

I have been practicing autopsy since 2018 and logged around 200 cases, and at present I spend one morning in the mortuary (yes, post mortems happen first thing in the morning and not the dead of night during a thunder storm) every fortnight, and on average do three autopsies in a session. For this I rely on my anatomical pathology technician/technologist (APT) colleagues who remove the organs once I have identified and externally examined the body, then I perform organ dissection where I weigh and cut into each organ in an attempt to identify the cause of death. If there is nothing obvious on first examination then I take blocks of tissue from the organs to examine under the microscope (under the authority of the Coroner), blood and urine for toxicology depending on the history, and sometimes samples for microbiology. At the conclusion of the Coroner’s investigation, the next of kin are asked what they would like to happen to the tissue as I’ve mentioned earlier.

My routine practice in relevant cases includes taking blocks from the heart, lungs, liver, and kidney. These tissue blocks are placed in plastic cassettes, and into a pot of formalin to “fix” (preserve and firm up the tissue). After around 24 hours the cassettes can be placed on a tissue processor which carries out a few important steps. First the tissue is dehydrated with alcohol, then the alcohol is washed out with xylene, the tissue is infiltrated with paraffin wax. Following this the tissue is embedded in a block of wax so very thin slices (4 micrometers) can be taken. These slices are placed on glass slides then stained with haematoxylin and eosin and they’re ready to be examined under the microscope. There is a lot of work to take tissue from the body and get it into a form with which we can diagnose disease!

All this work could not be possible without the fantastic laboratory staff in cellular pathology who are working under incredible pressure with ever increasing workloads. Pathology in the UK is under threat, with a shortage of laboratory staff and pathologists, and increasingly complex cases. Add to that the additional pressure of government cancer targets and you can see we’re in real trouble. WIthout pathology, there would be no concrete cancer diagnostics. There are no shortage of jobs if you’re interested!

It’s a long road to get here, and not for everyone, but pathology is a fascinating job and I hope this gives you a little insight into what this career entails.