Autopsy around the world

Claire Chambers wonders whether autopsies should be compulsory in undergraduate medical education

Should autopsies be a compulsory part of the curriculum? This is the question often asked by academics, doctors, and students alike. There are many potential benefits and disadvantages, but most students will never see an autopsy or postmortem examination or necropsy as they are also known.¹

Constantino margiotta/spl
Begin an autopsy with Y-incision

What is an autopsy?

A clinical autopsy is the final step in the identification of a person's illness or cause of death. Medicolegal autopsies have legal implications and try to determine whether a death was unintentional, homicide, suicide, or a natural event. The word autopsy is derived from the Greek word autopsia-"to see with one's own eyes."

Without an autopsy, the cause of death can be wrong in as many as 30% of cases, but autopsies do not always provide the cause of death.² In England and Wales a hospital (clinical) autopsy requires the consent of the patient's family, unlike a coroner's autopsy examination, which is required by law. A medicolegal (coroner's) autopsy will be requested in these circumstances:

• All unattended deaths (where the doctor has not seen the patient within 14 days)
• Unknown cause of death
• Unidentified deceased
• Unnatural or potentially unnatural deaths.

Clinical autopsies help the medical profession by providing information that could not be discovered in any other way. Much of what we know comes from autopsies. They help to:

• Identify the cause of death
• Confirm the nature of the illness and extent of disease
• Identify other undiagnosed pathologies
• Assess the effectiveness of treatments and drugs, and identify any adverse effects.

Anatomy and pathology

An autopsy can help a bereaved family to understand why their loved one has died and can enable doctors to answer their questions. The information gained might also benefit future generations of the family, if the deceased person died of an inherited disorder. Autopsies also help other patients because of the information collected.

After the experience of the dissecting room you think you have seen the worst of medicine and you can cope with any situation that will arise in your career. But you have seen nothing until you experience an autopsy. I feel autopsies would be of huge benefit to students who do not have the opportunity to dissect. How else are they going to prepare themselves with death and the kinds of emotions that young people have not previously experienced? Students who do not dissect will possibly be at a serious disadvantage. This is one reason why I advocate the introduction of autopsies into the undergraduate curriculum.

Autopsies have other gains for students too. Learning anatomy from a fresh body is so different from learning from a cadaver. A cadaver does not bear much resemblance to a living body: to the uninitiated, it is difficult to distinguish between a nerve fibre and a blood vessel. Also, the chemicals used to preserve cadavers combined with changes after death make the consistency of the tissue and organs different from that in living patients.

On my visit to the mortuary I was taught a wide range of anatomy, from the substantia nigra in the brainstem to the vasa vasorum of the aorta. This was especially useful because medical schools are phasing out anatomy teaching by dissection, in favour of prosections, books, and computer models. But I found learning on a real body, especially a fresh one, much more useful because I could orientate myself. The anatomy is so much more fascinating and life-like.

Making it compulsory for students to attend an autopsy would give pathology more exposure because currently few UK graduates enter pathology. Pathology is the fundamental basis of medicine and surgery and the foundation of diagnosis and therapeutic intervention, yet fewer medical students are now considering a career pathway in the pathology specialties.³

The Royal College of Pathologists has proposed that at least 10% of all second year foundation programmes should include an element of pathology learning. This will not only encourage trainees to consider a career in pathology but will also allow those who have career aims elsewhere to understand the importance of laboratory medicine in clinical decision making.⁴

Attending an autopsy gives firsthand understanding of the procedure, what it entails, how the body is likely to appear afterwards, and the benefits and limitations of the examination. Students also gain an understanding of the role of the autopsy in quality control and research and learn how and why to request permission for autopsy and to discuss the procedure knowledgeably with relatives.⁵ These lessons are so important that some people argue that a lack of understanding of autopsy by recent medical graduates who have never attended one has contributed to the decreasing rate of autopsies.⁵

Arguments against making medical students experience an autopsy include that it may be too much for some. Also, students may find autopsies so unpleasant that it discourages them from considering pathology as a career.⁶

Technological advances in diagnostic tests and imaging have challenged the value of autopsies. This, along with concerns about informed consent and the retention of organs, has made clinicians reluctant to request an autopsy,⁷ therefore, opportunities for all students to view one may well be limited anyway. Furthermore, histopathology in the United Kingdom faces serious staff shortages and increasing workloads so that the unavailability of autopsies and a lack of staff to teach about them make autopsy teaching impractical.⁸⁹

Problems surrounding consent

After the Alder Hey Children's Hospital scandal, in which children's organs were retained without consent, how doctors get consent for autopsies has changed. Relatives are asked to choose which whole organs, if any, are retained. They are then informed that after the autopsy the organs must be disposed of in a lawful way.

They are given the option of the organs being reunited with the body before it is released, even though this may delay the funeral. Alternatively, they can arrange for the organs to be disposed of by the funeral director, or they can request that the hospital dispose of the organs in a "lawful and respectful way." Finally, they are asked to agree or disagree to some tissue, fluids, or organs being taken and held for an unlimited time for medical research and education.

There's the experience

The shock that hits you as you walk around the corner into the mortuary, to be faced with dead bodies is unexpected. I thought having done dissection for two years that I was hardened and it would be a walk in the park. But these are real people with their history pinned up at the end of their table. Cadavers in the dissection room are grey, withered models. Seeing a cadaver for the first time in the dissection room was a shock, but that was because we are mostly young innocent students, usually coming from our parents' nest. In the mortuary it's a different story: there is so much blood and gore, and it's more real. Some of the sights you see really bring home what medicine has in store. Because of my experiences in the mortuary I will definitely be a better, more empathic doctor.

So far it has been all textbooks, and to be thrown into a ward with real people is a serious situation to have to adapt to. It is hard to go from textbook to death and expect us to be prepared and to deal with emotions.

Autopsy around the world

Many medical students graduate without seeing an autopsy,¹ but in some countries they may be the only medically qualified person to undertake the task. In India, for example, according to the curriculum of the Medical Council of India, a medical student should witness medicolegal autopsies in the second year so they can observe and interpret the findings. An intern is supposed to acquire the skill of doing a medicolegal autopsy. So any medical graduate is presumed to be capable of doing a medicolegal autopsy.¹⁰

In Australia, medical students used to be expected to attend routine hospital autopsies.¹¹ But anecdotal evidence shows a decline in human dissection and autopsies for teaching in Australian medical schools. The key reason for the decreasing use of autopsies by university pathology departments is the decrease in the rate of hospital autopsies and the growing field of non-autopsy pathology, including molecular and cellular pathology.¹¹ Student attendance at autopsies is compulsory in five medical schools.

In Nigeria, students spend four months in the pathology department and observe autopsies. In a study of attitudes of Nigerian medical students towards autopsy,¹² 97% of the students agreed that autopsy is necessary, and 96% agreed that they learnt something from watching and participating.

The United States does postmortem examinations after fewer than 5% of deaths in hospital, and the procedure is alien to almost every doctor trained in the past 30 years.¹³ Fewer than half of US medical schools require attendance at autopsy, and most students graduate without attending a single session.¹⁴

The use of autopsies to teach medical students has been falling worldwide in the past few decades. In 2002, however, Auckland, New Zealand, took the unprecedented step of legally prohibiting students from attending autopsy teaching, by barring them access to coronial autopsies, under an interpretation of New Zealand's coroners act. Until recently, learning from autopsy was vibrant in Auckland. Many medical students from the third year and above voluntarily attended daily autopsy teaching and were enthusiastic about this method of learning. The ban was made after widespread media coverage of the discovery that children's hearts removed at autopsies had been retained for teaching without the families' consent.¹⁵

In general, throughout Turkey a general practitioner often does forensic autopsies and examines legal cases because there are not enough forensic medicine specialists.¹⁶¹⁷ Undergraduate forensic medicine education must be taken by every medical student in Turkey.^16-18

In Brazil, students are encouraged, but not obliged, to attend necropsies. They are most likely to attend necropsies during the final two academic years.¹⁹

Religious stance on autopsies

Rates of autopsy throughout the world have been in progressive decline.²⁰ Religious objection is often cited as a cause, but few religions take a stand against autopsies.²¹

The role of the autopsy is often undervalued in the medical curriculum. Many schools hold demonstrations of autopsy material but few offer the opportunity to take part in the autopsy, analyse the findings, and prepare the report.²²This looks like the reality for the near future unless something is done about it.

Claire Chambers, third year medical student, Leeds Medical School
Email: clc26@le.ac.uk

Competing interests: None declared.

studentBMJ 2007;15:1-44 January ISSN 0966-6494

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2. A guide to the post-mortem examination procedure, www.doh.gov.uk/tissue/pmadultinfo.pdf (accessed 17 Feb 2006).
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4. Swift B, Stanworth S, Newland A. Careers in pathology. BMJ Careers 2004;329:187-90. http://careerfocus.bmjjournals.com/cgi/content/full/329/7474/187-a
5. Benbow EW. Why show autopsies to medical students? J Pathol 1990;162:187-8.
6. Burton JL. The autopsy in modern undergraduate medical education: a qualitative study of uses and curriculum considerations. Med Educ 2003;37:1073.
7. Perkins GD, McAuley DF, Davies S, Gao F. Discrepancies between clinical and post-mortem diagnoses in critically ill patients: an observational study. Crit Care 2003;7(suppl):s129-32.
8. Start RD, McCulloch TA, Benbow EW, Lauder I, Underwood JCE. Clinical autopsy rates during the 1980s: the continued decline. J Pathol 1993;171:63-6.
9. Burton JL, Underwood JCE. Autopsy practice after the organ retention scandal: requests, performance and tissue retention. J Clin Pathol 2003;56: 537-41.
10. Medical Council of India. Regulations on graduate medical education 1997. New Delhi: MCI, 1997: 28-9,85.
11. Russell KF. The Melbourne Medical School 1862-1962. Melbourne: Melbourne University Press, 1977. www.mja.com.au/public/issues/176_02_210102/par10727_fm.html (accessed 18 Feb 2006).
12. Ekanem VJ, Akhigbe KO. Clinical investigation: attitudes of Nigerian medical students to autopsy. Turk J Med Sci 2006;36:51-6.
13. Dobbs D. Buried answers. New York Times Magazine 2005 Apr24.
14. Anderson RE, Hill RB. The current status of the autopsy in academic medical centers in the United States. Am J Clin Pathol 1989;92(suppl): s31-7.
15. Coddington D. Heartbreak hospital. North and South Magazine 2002 Jun: 28-41.
16. Inanici MA, Birgen N, Aksoy ME, Alkan N, Batuk G, Polat O. Medico-legal death investigation and autopsies in Istanbul, Turkey. J Clin Forensic Med 1998;5:119-23.
17. Salacin S, Çekin N, Özdemir MH, Kalkan S. A questionnaire survey applied to undergraduate students who have taken the course on forensic medicine. Bull Legal Med 1997;1/2:21-4.
18. Tuncer I, Salacin S, Erkocak EU. The importance of education in forensic medicine for medical students in Turkey. In: Annual Report of Association For Medical Education in Europe, September 2-9, Münster, Germany, 1989.
19. Botega NJ, Metze K, Marques E, Cruvinel A, Moraes ZV, Augusto L, et al. Attitudes of medical students to necropsy. Clin Pathol 1997;50:64-6.
20. Pathmanathan R, Chandrasekharan N. Declining post-mortems: a cause for concern. Med J Malaysia 1985;40:267-70.
21. Svendsen E, Hill RB. Autopsy legislation and practice in various countries. Arch Pathol Lab Med 1987;111:846-50.
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	Responses published this month

Articles	Responses
LIFE Autopsy around the world       Claire Chambers (January 2006)	Rachna Bajaj (December 24th, 2006) Read this response
LIFE Autopsy around the world       Claire Chambers (January 2006)	Claire Chambers (December 28th, 2006) Read this response

	LIFE Autopsy around the world        Claire Chambers (January 2006)
	Rachna Bajaj (December 24th, 2006)        Medical student, The Royal Free and University College Medical School, University College London r.bajaj@ucl.ac.uk
	Editor, The lack of exposure that today's medical students have to autopsies is indeed a very disturbing trend. This lack of knowledge about the value of autopsies is also one of the major reasons cited for the declining rates of autopsies in the world. Future physicians are bound to lose out on benefiting from perhaps what can be called medicine's best teaching tool to improve diagnostic acumen if they neglect learning from autopsies. Indeed, discrepancy rates between the post-mortem and ante-mortem diagnosis in recent years have been reported to be about 40%, despite diagnostic technology being available to help us. Hence doctors-in-training should use and benefit from autopsies to improve their own diagnostic skills, as this may help them save lots of lives in their future careers. After all, Sir William Osler, father of American medicine, believed that a student's ability to learn from a wrong ante-mortem diagnosis laid the foundation to make a great diagnosticia n. References Lundberg GD. Low-Tech Autopsies in the Era of High-Tech Medicine: Continued Value for Quality Assurance and Patient Safety. JAMA 1998 280: 1273-1274. Rodin AE. Osler's Autopsies: Their Nature and Utilization. Medical History 17 (1973) 37-48.

	LIFE Autopsy around the world        Claire Chambers (January 2006)
	Claire Chambers (December 28th, 2006)        4th intercalating, leicester medical school clc26@le.ac.uk
	I am claire chambers the author of the article, and i wish to point out i am NOT from Leeds medical school, but leicester medical school.