Resuscitating the teaching autopsy
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7418.803 (Published 02 October 2003) Cite this as: BMJ 2003;327:803
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I couldn't agree more with Prof Underwood's comments on the benefits
of the teaching autopsy. I graduated from Sheffield Medical School where
there is an excellent, structured Pathology teaching programme and I
recall the many occasions where we were taught Pathology at autopsies.
Looking back, it made so much sense seeing the clinical relevance of what
could otherwise have been a potentially tedious subject for many medical
students. I have used many of the principles even up to my MRCP exam
preparations and beyond. With the gradual decline in hospital post-mortems, medical schools should seriously look into the Coroners post-mortems as an effective teaching tool. It's value would not be confined to
pathology but anatomy too, especially with the virtually non-existent
gross anatomy courses in many of our medical schools these days.
Competing interests:
None declared
Competing interests: No competing interests
In common with Underwood, I too lament the demise of the post mortem
to the sepulchre of medical education. He draws our attention to the fact
that 90% of post-mortems in UK hospitals are now Coroner's cases.
However, neither he nor O'Grady mention that a significant financial
incentive exists for many pathologists to perform a Coroner's post-mortem
rather than a hospital one. As a naive SHO I recall pleading with a
Consultant Pathologist to perform a hospital PM on one of my patients,
mainly for teaching purposes. He was insistent I referred the case to the
Coroner, even though I was clear as to the cause of death and there were
no suspicious circumstances. It was only later I discovered that
Consultant Pathologists at that hospital (but not my current institution)
received a substantial payment for each Coroner's PM they performed. When
a pathologist performs a Coroner's PM, the report and findings belong to
the Coroner and the teaching of doctors and medical students becomes an
incidental issue.
I have little time for the "witch-hunt" that followed the retention
of organs from Coroner's PMs in the UK, but perhaps it did focus minds on
the difference between Hospital at Coroner's PMs. Isn't it about time
that personal financial gain was taken out of the equation?
Competing interests:
None declared
Competing interests: No competing interests
Resuscitating the teaching autopsy
Your authors each make points which have been made previously, but
two write from outwith the United Kingdom. Underwood, as the President of
the Royal College of Pathologists, necessarily has to make his comments
with care. A local district general hospital has performed less than half
a dozen NHS autopsies in the last year, in common with the decline in
numbers elsewhere, and some of my hospital colleagues are reticent in
considering autopsy and requesting one.
Every time I report a death to the coroner, I am asked whether there
is a possibility that I could certify the cause of death. My invariable
response is to say my contacting the coroner is precisely because I am not
sure of the cause of death. The usual riposte to that is that other
colleagues feel able to certify the cause of death in such circumstances,
and I was recently asked if I was aware of the cost of an autopsy. I was.
In that case, myocardial infarction was the suggested cause of death
for me to provide to save the coroner the cost of an autopsy. Autopsy
showed an unsuspected ruptured abdominal aortic aneurysm, a condition with
a known familial incidence, with possible implications for family members.
I would further suggest that the events of Bristol and Alder Hey, as
well as cost, have pressured coroners’ pathologists not to perform
histological and microbiological examinations, which further contributes
to the downgrading of quality of the autopsy.
Yours faithfully
M G Bamber
Competing interests:
one year in a prolonged undergraduate career attached to a Home Office pathologist, and a subsequent three years attending at least one teaching autopsy per week.
Competing interests: No competing interests