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Rapid Responses: Rapid Responses published:
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Autopsy as an educational tool in Indian Medical Schools
- Dr. Vikas Dhikav (4 October 2003)
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Autopsy findings are important to all clinicians, including general practitioners.
- Brian S Hurwitz, Berry Beaumont (6 October 2003)
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Autopsy and Imaging
- Ian C Bickle (6 October 2003)
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Re: Death of the teaching autopsy
- Guy N Rutty (7 October 2003)
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Lack of teachiong Autopsy is a UK Problem also.
- Robert Mulholland (8 October 2003)
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A need to champion the teaching autopsy, the HKU experience.
- Philip SL Beh (9 October 2003)
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Dearth of interest in teaching autopsy
- Jeremy M Rawlins (15 October 2003)
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Autopsy and Dissection.
- Prof.Owen L. Wade (21 October 2003)
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The autopsy as a research tool versus the arrogance of twenty-first-century medicine
- Gema Frühbeck (2 November 2003)
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Death of the teaching autopsy
- Dinesh N Ratnapala (10 November 2003)
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Dr. Vikas Dhikav, Resident All India Institute of Medical Sciences, New Delhi-110029, INDIA
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Use of autopsy as a learning tool is invaluable as it teaches what is unlikely to be thought by other source. This not only gives real-time experience and the feeling of working over human body-the final responsibility of a doctor, but also provides lifetime opportunity to learn structural details. However, there has been an unfortunate decline1 in use of autopsy as learning tool for medical students. Situation in India is nearly same as Auckland or worse. Barely a handful of over 250 registered medical colleges are using autopsy to teach students now a days. About the same number of private medical colleges never use bodies for teaching purposes and teach human anatomy just on dolls and dummies! The reason for this situation is, however, not the extensive media campaigning but the firm Indian belief that, if they allow bodies to be dissected, then the individual will be born mutilated. For this reason, the rate of organ donation is among the lowest of all countries. Most people would decline autopsy if they were given a choice, let alone donating body to a medical school for learning. This situation is reflected by the fact that in All India Institute of Medical Sciences, primer Indian Medical Institute, there are only handfuls of cornea available for transplant, and not more than a dozen of all other organs at a given time. Situation in rest of Indian hospitals is same or even worse. This is notwithstanding extensive media campaign and a population of over a billion people. Then what is the solution? The education! What we need is to persuade people to remove their doubts about autopsy and organ donation. Unless masses are convinced, medical students would have to depend on dolls and dummies for learning human anatomy. 1. Gregory O'Grady. Death of the teaching autopsy. BMJ 2003;327:802- 803 Competing interests: None declared |
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Brian S Hurwitz, Professor of Medicine and the Arts, King's College, London King’s College Strand, London WC2R 2LS., Berry Beaumont
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Dear Richard Smith In his article, ‘Death of the teaching autopsy’, Gregory O’Grady identifies several reasons why autopsy rates have been falling worldwide, and why, in particular, students in New Zealand are now banned from attending autopsies (a consequence of unconsented organ retention practices), with resultant loss of undergraduate teaching opportunities.(1) However, the processes of attending and watching an autopsy are not the only educationally relevant facets of autopsies. Autopsy findings are important to all clinicians, including general practitioners. In 1991, Whitty et al (2) found that autopsy findings (excluding coroner’s reports) were poorly communicated to GPs in four districts in the North East Thames Region. GPs received reports from only 39 of 89 (47%) autopsies performed on their patients. In our study of deaths in a general practice (n=578) which ascertained 97.8% of all practice deaths over a 15 year period, the value of a death register in contributing to clinical governance was severely curtailed by lack of cause of death information. (3) Over the 15 year period, 143 (24.7%) deaths were reported to the coroner, a percentage comparable to the UK average for all deaths. However, in only 4 (2.8%) of these deaths was the practice routinely sent a coroner’s report on the results of the autopsy investigation. After contacting relevant coroners specifically to request cause of death and autopsy information, no report was provided on 65 (61.3%) occasions (see table), an experience similar to that reported from Manchester.(4) Given the pivotal position of general practice within the UK NHS, these findings point to significant disconnection of autopsy services from clinical services. O’Grady laments the development of a vicious circle, whereby lack of student contact with autopsies means clinicians will no longer be ‘advocates of autopsies’. Since 90% of all autopsies in the UK are now performed by coroners (5) it is not surprising clinicians should feel unable to advocate autopsies. Failure to feedback autopsy information to GPs represents a lost educational opportunity on an enormous scale, which could fairly easily be corrected. Frequency with which coroner’s reports were received (August 1985 to July 2000) by an inner London general practice. Coroner’s report Freq % Received unsolicited 4 2.8 Requested and received 41 28.7 Requested not received 65 45.5 Not requested/not received 27 18.9 Verbal information only 6 4.2 Total 143 100.0 Yours sincerely Brian Hurwitz
Berry Beaumont
1. O’Grady G. Death of the teaching autopsy. BMJ 2003; 327: 802-3 2. Whitty P, Parker C, Pietro-Ramos F,Al Kharusi S. Communication of results of necropsies in north east Thames region. BMJ 1991; 303: 1244- 1246. 3. Beaumont B, Hurwitz B. Is it possible and is it worth keeping track of deaths within general practice? Results of a 15 year observational study. In press QSHC (expected date publication Oct 2003). 4. Webb R, Esmail A. An analysis of practice-level mortality data to inform a health needs assessment. BJGP 2002; 52: 296-299. 5. Underwood J. Commentary: Resuscitating the teaching autopsy. BMJ 2003; 327: 803-4. Competing interests: None declared |
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Ian C Bickle, SHO, Neurology Royal Victoria Hospital, Belfast
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Editor: I respond with interest to O'Grady's article. The teaching of autopsy is a natural element of undergraduate anatomy teaching - both areas in decline in the modern medical curriculum. This is ironic given the rapidly expanding and ever popular speciality of imaging (radiology) contemporary medicine. Given that a large part of imaging requires the interpretation of normal structures and pathology in the art of diagnosis surely anatomy/autopsy should be more important than ever in teaching medical students. The Department of Anatomy at The Queen's University of Belfast (in conjuntion with The Royal Victoria Hospital's Imaging department) has recognised this for some time. Radiologists are actively involved in the teaching of anatomy from an early stage. Sadly the anatomy demonstrator posts, which would be excellent for budding radiologists, no longer have clinical approval and compulsory attendance at autopsy died some years ago. Competing interests: None declared |
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Guy N Rutty, Professor of Forensic Pathology University of Leicester LE2 7LX
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Lack of teachiong Autopsy is a UK Problem also. | 8 October 2003 | ||
Retired surgeon
34 Regent St nottingham NG5 4 DD
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Re: Lack of teachiong Autopsy is a UK Problem also.
Clinical Asst. Professor (Forensic Pathology), Department of Pathology, Faculty of Medicine, The Uni
Queen Mary Hospital, Hong Kong
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Re: A need to champion the teaching autopsy, the HKU experience.
O'Grady's comments regarding autopsy teaching are shared by many of us who have had the fortune of going through medical school when autopsy teaching played a significant role in the curriculum. Here, in Hong Kong we too have experienced the gradual general decrease in the number of consent hospital autopsies so much so that at the major teaching hospital where I am at, we now only see 20-30 cases a year! This coupled with our switch to the new Problem-Based Learning Medical Curriculum in 1997 brought autopsy teaching to the verge of extinction.
We have managed to preserve autopsy teaching for our medical students with the help of our colleagues in the public mortuaries where over 4000 Coroners' autopsies are performed each year. During the 2nd year of their medical school students are rotated in groups of 8-10 students to the public mortuaries where they may observe a detailed autopsy of a case or in some instances snapshots of many cases depending on what cases are seen that day. The students are required to write about their expectations prior to such a session and to reflect upon their experience after attendance at such a session. Their written reflections confirm the comments quoted in O'Brady's paper in that they reflect the development of an awareness of death and the emotions related with death. Others write about the wastefullness of suicide. Some comment on the vividness and clarity of anatomical structures or pathological lesions. Yet others comment on the complexity of integrating the information from autopsy findings with the clinical presentation and progress.
We have further enhanced this latter aspect by redesigning our teaching clinicopathological conferences. In our current "new" format. Students are allocated a case and they are provided with the case notes, radiographs, biopsy and autopsy reports, etc. They are encouraged to seek the help of teachers and can invite teachers to attend their presentation to the class to comment on specific areas or issues related to the case. The entire presentation and discussion is however done by students with a teacher holding only a watching brief. A total of nine such sessions are held in the third year of our curriculum.
Unfortunately, the curriculum cannot allow us to have more of the autopsy teaching sessions and further autopsy teaching is only available to students as special study modules.
This arrangement is possible because like the UK situation there is no explicit interpretation of our Coroners' Ordinance that prohibit the attendance of autopsies for the teaching of medical students, police officers, etc.
I would like to encourage O'Brady to seek the support of his colleagues and perhaps even the New Zealand public and make representations to the Coroner to review the decision to forbid student attendance at Coroners autopsies. Teaching autopsies need championing and are worth the energy and effort.
Competing interests: I coordinate the autopsy teaching and the clinicopathological teaching sessions of our undergraduate medical students.
| Dearth of interest in teaching autopsy | 15 October 2003 |
Research Fellow
University of Bradford
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Re: Dearth of interest in teaching autopsy
Dear Sir.
It was with great interest that I read "Death of the Teaching Autopsy."1 Shocking as it is that students in Auckland are now barred the opportunity to observe post mortem examinations, I suspect the level of medical student interest in autopsy has been dwindling for years! As a pre-clinical medical student in the UK 10 years ago, attendance at autopsy was an "optional extra" of the 2nd MB pathology module. Being one of only two students who took-up the offer to observe a mornings work in the autopsy room, we were greeted by pathologists and mortuary technicians falling over each other to teach us. We were expertly shown gross pathology such as pulmonary emboli, coronary thromboses, brain haemorrhages and renal tumours. What we saw we remembered infinitely better than anything we had read about in our textbooks. Most importantly however, we saw for ourselves the high level of respect the bodies were given, before, during and after post mortem. They were certainly not mutilated or disfigured as so many medics and non-medics envisage they are.
Later in my postgraduate surgical training, as part of a critical care course a fellow trainee was asked to role-play with an actor the rather unpleasant task of asking a recently bereaved relative permission for post mortem examination. Having clearly never attended an autopsy she nervously described a horrific turn of events that was far removed from the reality of a conventional post mortem examination. The relative refused permission for autopsy!
To avoid difficult scenarios such as the one above, students and junior doctors should be encouraged to attend post mortems. Whilst I would commend McDermott as a pathologist taking on the responsibility of counselling the relatives of patients undergoing autopsy, I feel that clinicians should remain involved in the process (as happens at McDermott's institution).2 Post mortem is an essential tool for furthering our understanding of disease and death. If students and junior doctors fail to understand the importance and implications of autopsy, not only are they failing themselves, but they are failing their patients', and indeed their patient's relatives also.
1 O'Grady G. Death of the teaching autopsy. BMJ 2003;327:802-803. (4 October)
2 McDermott M. Obtaining consent for autopsy. BMJ 2003:327:804-806. (4 October)
Competing interests: None declared
| Autopsy and Dissection. | 21 October 2003 |
retired
Stratford on Avon CV37 6DN
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Re: Autopsy and Dissection.
The Editor, BMJ.
Dear Sir,
I know how much I have learnt, first in the dissecting room when I was a student, and then in the autopsy room during my professional life. This has helped me greatly to help my patients and that is what all doctors wish to do.
I personally value greatly the idea that after my death my body, no longer any use to me, will be dissected by a future generation of medical students. But if by chance it is not suitable for dissection I would like it to be used in the autopsy room to demonstrate the pathology that caused my death.
I commend this view not only to my professional colleagues but also to the public - and perhaps especially to journalists who influence the public, so often inappropriately, on this subject.
I am
Yours sincerely
O.L.Wade MD, FRCP. Qualified 1944.
Competing interests: None declared
| The autopsy as a research tool versus the arrogance of twenty-first-century medicine | 2 November 2003 |
Clinical Scientist
Dept. of Endocrinology, Clinica Universitaria de Navarra, Univ. of Navarra, 31008 Pamplona, Spain
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Re: The autopsy as a research tool versus the arrogance of twenty-first-century medicine
The moribund state of autopsies has been clearly established by O'Grady (1). One of the proposed reasons for this circumstance is an increased confidence in new diagnostic tools, particularly modern imaging techniques (1, 2). Surprisingly, the rates at which misdiagnosis was detected in autopsy studies (about 40%) had not improved from 1960 and 1970, before the advent of computerised tomography, ultrasound, nuclear scanning, and other technologies, compared to 1980, after those technologies became widely used (3). In 2003, the most recently published systematic review on rates of autopsy-detected diagnostic errors, of 53 autopsy series identified, 42 reported major errors (i.e. clinically missed diagnoses involving a primary cause of death) and 37 reported class I errors (those most likely to have affected patient outcome) (4). The median error rate was 23.5% (range: 4.1-49.8%) for major errors and 9.0% (range: 0-20.7%) for class I errors. Advances in imaging and diagnostic technology have not reduced the value of the autopsy. Goal-directed autopsies should remain a vital element in the assurance of medical care excellence. Moreover, autopsies could serve as indicators of overall performance of care systems compared over time or among themselves (5). For this purpose comparable methods should be applied to sample deaths in health care systems with autopsies and chart reviews to assess quality management, reasonable decision making and appropriateness of provided care. Actually, autopsies are called to play an important role in monitoring quality among a population with an increasing proportion of geriatric and obese patients with polypathology and co-morbidity.
In addition to their intrinsic clinical interest, missed diagnoses detected at autopsy may have important implications for research. Medical records contain substantial inaccuracies regarding the principal diagnoses causing or contributing to death. These inacccuracies have important policy implications, as major funding and policy decisions derive in part from vital statistics and other estimates of disease burden. By the turn of the twentieth century Virchow, Rokitansky and Osler defended autopsies as a research tool to prevent misdiagnoses. Once doctors had insured a dignified and respectful dissection of the body relatives of the deceased no longer viewed autopsies with suspicion. Autopsy literally means "to see for oneself". It would be as foolish to think we have reached the limits of human knowledge as it is to think we will some day know everything. There is always, and will ever be, scope for improvement, to learn from knowing when our certainties are simply wrong.
1. O'Grady G. Death of the teaching autopsy. BMJ 2003;327:802-4.
2. Burton EC, Troxclair DA, Newman III WP. Autopsy diagnoses of malignant neoplasms. How often are clinical diagnoses incorrect? JAMA 1998;280:1245-8.
3. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med 1983;308:1000 -5.
4. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time. A systematic review. JAMA 2003;289:2849-56.
5. Lynn J, Cobbs E, Orenstein J. Autopsy rates and diagnosis. JAMA 1999;281:2181.
Competing interests: None declared
| Death of the teaching autopsy | 10 November 2003 |
Resident Medical Officer
Redcliffe Hospital Locked Bag 1 Redcliffe 4020 QLD Australia
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Re: Death of the teaching autopsy
COMMENT TO THE EDITOR BMJ
Death of the teaching autopsy
EDITOR – O’Grady’s lamentation and Professor Underwood’s reply are spot on. I myself attended no less than 350 teaching autopsies as an undergraduate at Auckland. The invaluable clinical lessons learnt, and intuitive clinical sense gained from immersing oneself in the ultimate audit in medicine, the autopsy, time and time again, with all five senses, in all its disease and constitutional permutations is indescribable.
Not learning from autopsies is akin to a trainee mechanic never seeing the inside of car engines. Would you take your BMW or precious Toyota to such a technician? How about entrusting your own life or that of your nearest and dearest in the equivalent of such?
Medicine has tremendous and unique privileges, and requires the practicing of the art, never to be defeated and hindered by the follyed standpoints of a powerful and misinformed few. This is apparent in all aspects of society and the medical world is sadly no exception. Otherwise those who institute its hindrances should be held responsible for the damage done to the greater good of humanity, through the death of a teaching tool most important in clinical medical training, in this an increasingly litiginous world where the stakes of error and importance of clinical lessons are supreme.
Mortui vivos docent – let the living learn from the dead….with respect.
Dinesh Ratnapala
Resident Medical Officer
Redcliffe Hospital,
Queensland, Australia
dineshbrisbane@yahoo.com
Competing interests: attended 350+ autopsies at Auckland, NZ. Learnt my most important lessons from these.