The Doctors Whose Patients Are Already Dead

It takes five hours to disassemble the body.

The dead man—“H: 71 inches,” as scrawled on the autopsy-room whiteboard—is laid out on a metal table, head propped up on a plastic block. The body is naked, marked only by a neon-yellow hospital bracelet and a paper toe tag. The flesh—now grey and exposed—is stretched tautly over bone. The feet are swollen, blackening; all the muscles are tensed, the face thrown back. It’s a wan, triangular face, with few wrinkles for a middle-aged man. The chin is dotted with stubble.

The man had died eight hours earlier at a hospital in the University of Pittsburgh Medical Center (UPMC) hospital system, where the pathologist Jeffrey Nine directs the autopsy service. Nine suspects the man died of a heart attack, but the family wants to be sure, so Nine, his chief pathology resident, and two students training as pathologists’ assistants set to work performing an autopsy. (The man’s family wasn’t told that I would be present at his autopsy, but Nine made sure to shield me from any details that might identify the man.)

Families request autopsies for a number of reasons: They want closure; they want to see what role genetics played in someone’s death and how it might affect them in the future; they feel guilty and wonder if there’s anything they or their doctors could’ve done differently. Nine says that most of the time, there isn’t.

Because UPMC is a large teaching hospital, ranked among the top 20 medical schools by U.S. News & World Report, it’s one of the only hospitals in the country with the resources to run a centralized autopsy service and employ someone full-time to oversee it. When someone dies of natural causes in the UMPC system, the next of kin can elect to have an autopsy performed at no cost. The arrangement is intended to benefit both the hospital and its patients: In waiving its autopsy cost, UPMC helps grieving families, but also creates educational opportunities for pathology students. Autopsies are often performed by the hospital’s pathology residents—doctors who are still training but have already completed medical school—and pathologists’ assistants, or PAs, most of whom are pursuing a Master’s or another post-baccalaureate degree in the health sciences.

Unlike the crime-oriented forensic autopsy glamorized on CSI, the hospital autopsy is lower-tech and routine. The hospital caseload is far less than that of a medical examiner’s office, the typically county-run institution that does the forensic work of investigating violent or unnatural deaths (homicides). While medical examiner’s offices in larger cities might perform 10 or more autopsies a day—some in as few as 40 minutes—UPMC’s autopsy service performs about one per day, or approximately 350 autopsies per year. Though Nine could do a 40-minute autopsy, each autopsy at UPMC lasts three to six hours so that pathologists-in-training can be thorough.

For Nine, directing the service means supervising the revolving door of pathology students on various rotations and practicum placements, all of whom he helps train. Nine is in his mid-40s, avuncular, with brown hair and wire-rim glasses. He has Star Trek posters in his office on the sixth floor of UPMC Presbyterian, the central hospital of the system, and signs his emails “J9.”

Ellen Sun, a third-year medical student who’s completing a month-long rotation in the pathology lab, say she likes Nine. Everyone likes Nine. They talk about him at student recruitment dinners. To new students, who are anxious and inexperienced in the autopsy room, he projects confidence and calm. More importantly, they think he’s funny.

The autopsy I’m here to observe on a weekday morning is the hospital’s first in two weeks, so Nine and his chief resident, the first-year pathologist Brennan Mosch, are eager to work. The amount of time between cases has been a running joke. “Good for the patients!” Nine writes to me in an email the week before the autopsy.

“I can’t imagine a job without teaching,” Nine tells me. “I love students.” He treats me like a student, too, making me suit up properly before entering the autopsy room, explaining everything as we go. I’ve been forewarned that autopsies can get messy, bodily fluids everywhere, so I’m wearing torn jeans, ratty sneakers, and an oversized t-shirt from a Pittsburgh Pirates game. Nine tells me it’s a good autopsy shirt.

Everyone in the room is required to wear disposable garments that cover the body head to toe. I put on a blue, ankle-length, long-sleeved surgical gown, a plastic apron, a tie-on surgical cap, a clear plastic wrap-around face protector with a foam-cushion head strap that’s actually called a “splash shield,” shoe covers, sleeve covers the length of old-Hollywood evening gloves, and latex gloves. I most resemble a butcher.

Nine agrees. “The best way I can describe [the autopsy room] to you is it’s like a big industrial kitchen,” he says. It’s a comparison I’ll hear again: Every pathologist I talk to seems to enjoy pointing out the parallels between their work and cooking.

The room is stark and surprisingly spacious. Modular steel cabinets and a countertop span the back wall, where a row of tools is laid out on a cloth.

“It’s kinda not so much different than surgery in some aspects,” Nine says, showing me the tools: a couple of forceps (“to grab tissue with”), scissors, scalpels, a plastic container full of scalpel blades, stainless-steel rulers, a label-maker for specimens, a bright-red colander for washing organs. There are heftier tools for removing organs like the brain, including a thing that looks like a mallet, with a curved hook for leverage in pulling out bone. There are long, scalloped knives, identical to bread knives. A portable dishwasher sits along the opposite wall. Because of the condition of its patients, nothing in a morgue needs to be sterilized to the level of surgical tools, so these tools are cleaned on a less-stringent sanitary rinse cycle, like baby bottles.

“What we have is a combination of surgery implements and common garden tools and kitchen appliances,” Nine says. From inside one of the cabinets he pulls out a pair of green heavy-duty hedge sheers, at least two feet long. They’re used to crack open the rib cage, sometimes in lieu of a bone saw. “We use them like chopping limbs off a tree,” he tells me.

All autopsies at UPMC begin the same way: The autopsist makes three large, deep cuts into the body, forming the “Y incision.” The first two cuts start at the top of each shoulder, extending down diagonally toward the sternum. Then, a third cut is made where the first two intersect, a straight incision down the chest. The cuts barely bleed; after death, with the heart no longer pumping, only the pull of gravity creates blood pressure. Once cut, the chest is opened up with shears to remove the organs. Nine bought his shears at Lowe’s.

After those initial steps, the procedure can be modified for each case—to focus on “the money organs” in pathology, as Nine jokingly calls them. But that initial opening of the body is the hardest for non-pathologists to take. Nine thinks that it strikes many as profane—the way the body is manhandled onto the table, then violently pried open, bones cracking. But it’s a matter of practicality. A dead body is heavy, stiff, resistant. Force is the only way to get inside. The word autopsy literally means to “self-see”—from the Greek autos, self, and optos, sight.

The dead man’s chest has been cut wide open, and the techs have carved out all the major organs, save for the brain. They’ve been removed en bloc, meaning they were eviscerated in “blocks,” keeping the organs that have related functions together. On a separate table, all the biological systems that middle-schoolers learn about are grouped together on a single cutting board: thoracic organs (heart and lungs) in one block, and abdominal organs (stomach, liver, gallbladder, intestines, kidneys) in a mostly-connected second block. They like learning the en bloc method, one of the PA students explains, because it preserves organs’ anatomical relationships. The blocks make it easy to examine the way they interacted before death.

The organs are in a shiny, bloody pile on the plastic slab of cutting board, slushy whorls of jaundice-yellow lung crowning the whole thing. The liver—the largest organ in the body, after the skin—is sticking up, firm in the middle of the dripping blocks. I say to Mosch that the kidneys are the same color as beets. The blood, which is draining away from the organ heap onto the table and into the sink below, looks like pomegranate juice.

At one point, Nine draws my attention over to a “very important piece of technology.” He gestures at a computer where the pathologists enter their notes. “It has speakers so we can listen to music.” Though his residents like classic rock, Nine prefers video-game soundtracks. One of his favorites is the score from Guild Wars 2, a dragon-slaying game; the score is epic and symphonic, brass blaring over cellos.

Today, a Bach concerto is playing.

For the first 15 minutes, the man’s face is uncovered. It’s the first thing I notice when I walk in. After that, I can’t help but to keep glancing over at it from where I stand observing Mosch at the organ-block table. The eyes are still open, looking up, fixed on the ceiling. They look fearful, like they see an apparition that no one else can.

I wonder how they will talk about the body. I wonder if they’ll say it or he—

“Can you cover his face?” Nine asks the PAs—and they do, gently draping a white towel.

* * *

Like autopsy, the word pathology is from ancient Greek. Pathos—also the root word of empathy—can be translated as both “suffering” and “experience.” Friedrich Nietzsche thought of pathos simply as “that which happens.”

In medicine, pathology is the specialty that studies the cause and effects of diseases. Pathologists are most often found examining samples in a lab—biopsies, tissue samples, wounds. If you’ve ever given blood or a urine sample, a pathologist was likely the one on the other end, analyzing it and handing back your results. They also spend a lot of time advising clinicians about the condition of patients, helping them determine possible care and treatment. William Osler, an early 20th-century Canadian physician sometimes referred to as the “father of modern medicine,” called pathologists “the doctor’s doctors.” It’s a maxim that today’s pathologists still identify with.

Within the medical field, though, pathologists are often stereotyped as cold and detached, even creepy: They’re the doctors who don’t like patients; the ones who would rather hang out in basement labs all day.

In the history of pathology, it’s unclear exactly when the negative associations began. Though the scientific dissection of cadavers dates back to Ancient Greece, modern pathology has its roots in the mid-1850s, when the microscope came into widespread use. Until this time, pathology was considered a part of the general practice of medicine; physicians and surgeons identified disease by examining the affected parts of the body. But as cellular theory advanced in the 19th century, the German physician Rudolf Carl Virchow—known as “the father of modern pathology”—advocated that pathologists should specialize by moving from the study of organs to the study of cells, looking for parts of disease that could only be observed at the microscopic level.

“Life itself is but the expression of a sum of phenomena,” Virchow wrote in 1845, “each of which follows the ordinary physical and chemical laws.” He was among the first doctors to perform cellular-tissue analysis (histology), and instrumental in popularizing the idea that disease could be diagnosed this way. “Think microscopically,” he was said to have implored his medical students.

If Nine and his students are any indication, pathologists love talking up their field. Most of them, it seems, have a chip on their shoulder about their specialty. They think they’re the most maligned people in medicine. They tell me:

“It’s one of the least popular fields.”

“We’re like the cockroaches.”

“It’s the part of medicine that people forget.”

“We’re probably the most misunderstood, even by doctors.”

During the autopsy lull, Nine emails me a 1994 article from The New Physician, a journal for medical students, titled “Pathology: Myths and Truths.” “[P]athology is not simply one of the courses standing between medical students and ‘real’ medicine,” it reads. “Within our specialty, the principles of the basic sciences are artfully applied to very real, often complex, patient problems. Pathologists are not ‘locked up’ in the lab. They are constantly communicating with each other, healthcare workers, patients, laboratory personnel, and individuals in the community as they work to solve diagnostic problems.”

Dane Olevian, a first-year pathology resident, says the stereotyping starts in medical school. If you show interest in pursuing pathology, he tells me, many people view it as tantamount to saying you don’t want to deal with patients—the ethos of medicine. Your real interest isn’t people, but disease.

“All the generic people who came into medical school, your average doctor, what they would’ve said when they were in college—‘Why do you want to be a doctor?’ ‘I want to help people,’” Olevian says. “But you know what? You can help people in a million different type of jobs.”

Because they’re largely removed from patients, pathologists are stuck with an unromantic narrative. All medical specialties have their stereotypes, but others are at least more flattering: Pathologists aren’t known for being heroic prima donnas like surgeons. They’re not considered tender angels like pediatricians. They can’t be as righteous as OB/GYNs, who work some of the longest hours in medicine and have some of the lowest rates of job satisfaction.

But pathologists’ role in patient care is a significant one. When they see a sample or a slide, they’re the ones who tell a doctor what it is. Whatever’s in that once-mysterious sample—carcinoma, a nasal polyp, pancreatitis—it now has a name.

* * *

The first time I meet Mosch, he and one of the other pathology residents, Aaron Berg, are looking at case samples over lunch, brown-bagging it in their communal office space in the morgue.

I immediately identify with Mosch, a religion and philosophy major turned doctor. Of transitioning from the liberal arts to medical school, he says, “I almost didn’t make it.” He’s affable and talkative, happy to explain anything about his job. He calls pathology “the astronomy of medicine.”

“Because you need an instrument to look at the stars,” Mosch explains. He tells me that this is the speech that he gives to explain his specialty to friends and family. “There’s a whole universe, and it’s not something we directly have access to, but it’s always there,” he says. “So instead of looking at the world without through a telescope, we look for the world within through a microscope. And we see not millions of stars, but millions of cells and their interactions.” The sentiment harks back to a famous pronouncement of Virchow’s: Omnis cellula e cellula—every living cell comes from another living cell.

Berg and Mosch show me a slice of lung tissue under a microscope, directing my attention to where there’s abnormal cell growth. It looks healthy to me, with its splotches of orchid pink and purple. They gently tell me the lung is riddled with cancer: advanced carcinoma.

Being a pathologist isn’t just about labeling the slide as healthy or unhealthy, normal or abnormal, they explain. That’s the first step, but after you identify something as abnormal, you want to know what it is—and then, you start to speculate about what it might do. It’s not just about naming a thing, about static labels. It’s about observing the whole of the cellular universe. Everything is viewed as a “disease process.” This means pathologists are concerned with disease as something that progresses from its first diagnosis to its hypothetical final outcome: death.

Steve Hastings, another one of Nine’s former students and a fourth-year pathology resident, says, “Sometimes you can look at a slide and know in half a second exactly what disease process it is. You know that this person’s probably gonna be dead within a month… When you really sit there and think about it, it can be a quite moving thing.”

It falls to a pathologist to communicate that knowledge to the doctor.

“People don’t realize the pressure,” Olevian, the first-year resident, says. “It’s a final thing, too. It’s almost scary. No one has any clue what anything is. They pull it out or sample it and you say, ‘This is what it is.’”

“That’s a lot of power,” I tell him.

“It is.”

* * *

In the room, they’re examining the organs from inside the abdominal cavity. Nine shows Mosch which type of scissor is best for cutting hollow viscera. A hollow viscus is any organ that isn’t solid: The liver doesn’t count, for example, but the intestines do. “Think of it like manicotti for the body,” advises one post in an online forum for medical students. “It can be stuffed with things.”

Mosch: “He’s got a lot of, like… something goin’ on here.”

Nine: “A lot of like something goin’ on, huh?”

Nine lets the students take the lead, but when he does step in, his expertise—he’s performed more than 4,000 autopsies—is apparent. When Mosch has to make less-routine incisions to the heart because of a surgery the patient had, Nine shows him how to do specific cuts, maneuvering the scalpel with precision.

Every organ is weighed as it’s examined, plopped onto a hanging scale just like the ones for produce at grocery stores, and Nine and the students call out their weight estimates each time. Nine has a reputation for guessing right just by eyeballing. According to the “NORMAL ORGAN WEIGHTS” table, laminated and taped to the wall, the average male heart weighs 400 grams. But this one is oversized, hardened and ballooned from multiple heart attacks.

“All right, I’ll take 850,” one of the PAs says.

“No, I’m going 900,” Nine replies.

“901!” says Mosch, “Just like The Price is Right.”

The PA grabs the heart, plunks it down in the scale, watches the hand tick across the scale face. It weighs exactly 900 grams.

Midway through the autopsy, two PAs prepare to remove the brain, turning on an electric saw to make incisions into the scalp. Immediately, the saw blade falls to the tiled floor with a crash—it’s not fastened on tight enough. Nine says this happens sometimes. One of the PAs re-fastens it and begins to cut into the head, Mosch talking over the loud whirring across the room, his voice slightly muffled by the splash shield covering his face. He shows me the bowel, which he winds into a roll with two wooden sticks, like pigs in a blanket. At the same time, Nine and the other PA go into a side room to take photos of abnormal tissue they’ve carved out that might be significant for the case file.

Hours pass like this, the four of them pacing around each other taking samples, making cuts, asking questions, typing and jotting notes. The body, though it’s the object of investigation, becomes almost superfluous, literally dead weight in the room. After a while, it’s easy to become absorbed in the details of the work, to forget the larger context of where we are or what we’re doing. To forget death is a presence at all.

As more time passes, the organs gingerly examined one by one, I find myself inching closer to the table, wanting to touch one. I get so close that blood splashes onto my apron. Without thinking, I pull my spiral notebook to my chest, transferring a splotch of blood onto it. “Blood on the notes?” Nine asks. Without missing a beat, he douses the lined page with hydrogen peroxide and the blood disappears, leaving the ink intact.

“Not fainting?” Mosch asks me, now that I’ve been christened with my first bodily fluid. Nine has warned me it’s not uncommon to faint during your first autopsy. Some medical students faint. Even if they don’t faint at the beginning of the procedure, they faint in the middle, they faint at the end. Some make it through the first autopsy, then faint on the second or third. Nine once had a student who fainted every time she got close to the room. It took two weeks to get her inside. Another time a forensic anthropologist—a trained autopsy photographer—walked into the room and collapsed, narrowly avoiding the body and nearly breaking an expensive camera.

“You never know how your body’s going to react,” Nine says.

To my surprise, I don’t faint. Instead, I tell Mosch I can’t believe how big the liver is. This one weighs 1,760 grams, nearly four pounds, only slightly heavier than the average male liver.

“Do you want to touch it?” Mosch asks. I poke at it with my gloved hand. It feels like hardened foie gras. I see what the pathologists have been talking about: Maybe there is some less-than-subtle relationship between cooking and autopsies. All the blood draining into the sink below is passing through a bright-orange colander that Nine bought at TJ Maxx. One of the PAs ladles fluid out of the body’s open chest cavity into a plastic container. The ladle looks just like the gravy ladle in my own kitchen.

Nine says, “There’s a lot of similarity between this and cooking and kitchens and…”

“And Thanksgiving,” I say.

“… and Thanksgiving,” Nine repeats.

The PAs excitedly show me the crystalline gallstones they’ve cut out of the gallbladder. There’s a whole handful of them—centimeter-long triangular chunks that look like obsidian. They could be collectible gemstones.

“Sometimes they’re really pretty and chartreuse,” one of the PAs adds. Mosch tells me they’re really hard, usually yellow, made largely of cholesterol, which causes them to form when there’s too much of it in your bile. But these black ones are formed when your bile contains too much bilirubin, a chemical that’s produced when the liver breaks down red blood cells. Excess bilirubin can be caused by cirrhosis of the liver, which, in turn, can be caused by heart failure. I think of the organ blocks, how everything is connected.

After five hours, I’m happy when it’s finally time to dissect the heart. We’ve been standing the whole time, and I’m tired, hungry, and cold in the 65-degree morgue. The pathologists are bored and restless, too. They’re joking around, talking about the case less and less. Nine is explaining how to open up the aorta while talking about the movie Thor.

“My wife loves Thor. I even have kind of a guy crush on him. I just can’t imagine a cooler superhero. Now, what you wanna do here…”

Mosch makes precise centimeter-long cuts near the middle of the heart, running parallel to the groove between the atria and the ventricles, the top and bottom halves of the heart. Glancing at it, Nine says, “Well, it’s basically everything you’d tell a med student about what goes wrong with the heart.” Signs point to coronary-artery disease and heart failure.

Nine asks Mosch and the PAs if they can handle sewing up the body. They will place the organs back inside, then put the body back into refrigeration until the funeral home comes for it. The only things UPMC keeps are the slides and jars of samples.

The end of the autopsy is the most difficult part for Sun.

“We pretty much return a shell to the family,” she says. “We return the leftover pieces, cut-up pieces, in a big plastic bag. We put it—very messy—into the body and then we sew everything back up. But then nothing is perfect, because we don’t put the bones back together, so we just sew the skin over it. So the person’s chest just comes out a little bit, so it doesn’t look natural.”

They do a nice job with the head, Sun says, careful to replace the brain and to not damage the face. And the funeral home is very adept at making everything look presentable. But that image of the hollowness stays with her.

* * *

At the end of his six-week rotation with Nine, Mosch gives an autopsy “conference” for the other first-year pathology residents. He’s presenting the top cases from his rotation, to show his peers what he’s learned—kind of a greatest hits of his autopsy practice. In a wood-paneled classroom, Mosch and about a dozen pathology residents gather, doctors mostly in their late 20s. Mosch’s cases are all men over 50, two-thirds of them with heart conditions—the most common autopsy patient, he says. They’re so similar that Mosch can’t remember which case I observed.

The pathologists want to know how my first autopsy went. I say I’m surprised how banal it all was—how after only a few hours in the room, I was thinking about my feet hurting rather than the corpse five feet from me. I ask them: Do they still see any sacredness in death? Am I just being sentimental?

“The thing to recover sacredness, to me,” Mosch says, “the most astonishing thing, is to think: How was this all a person? Where is the person? Is the brain a person?”

Olevian chimes in: “That’s a person, sort of. Full of neurons.”

Olevian is quick to tie personhood back to the brain. He says the brain is like local memory on a computer: You lose access to information once it’s removed from a specific machine. Death is like removing local memory. The brain may still be there physically, but no longer contains all that unique data. That’s what’s lost to the world.

But Olevian and Mosch don’t feel much intimacy holding a brain, or any of the other organs. They’re impersonal. Pathologists spend all their time studying them, peering at slides of them. The cliché is true that death is a great equalizer, reducing everyone to a body, to their component parts. And that’s almost like seeing a person out of context—no person there.

“You get to see them completely removed from everything that made them human,” Mosch says. “Their family, their job, their interests, their clothing style, their everything.”

I want the pathologists to tell me where the line is, where they think a person begins and ends. I want them to name it, as they do everything else. They’re so close, straddling this metaphysical chasm; they must know. But they watch bodies roll in and they have the same questions. Mosch, the erstwhile philosopher, says he thinks about temporality a lot in the room.

But for all the talk of big ideas, it’s small things that get to him, Mosch tells me. Things like fingernail polish, tattoos. The guy wearing a necklace with his heart medicine in it. When they discover something like that on the table, he says, that’s when a body becomes human again.

Once, Olevian examined a man who died while out to dinner. He had a heart attack and paramedics couldn’t resuscitate him; they gave him chest compressions in the parking lot outside the restaurant. When the body got to Olevian, there were bits of leaves still in the hair. Suddenly, he could see it: the catastrophic scene with the man lying on the ground, the ambulance, his dinner mates’ shock and grief. He opened up the stomach and found pizza, pieces of dough and peppers and pepperoni.

“They were eating. I can envision it,” Olevian says. “This is what they did right before he died.”

You can’t plan for that, Mosch says, even with all your medical training. There are always these triggers. “And they are always things you don’t read about in a book.”