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Local forensic academics highlight autopsies’ role in medical education 

12 May 2022

  • Not only a positive tool in studying anatomy and pathology, but also helps students muster their emotional confidence
BY Ruwan Laknath Jayakody Undergraduates’ experience with autopsies should be enhanced by increasing exposure to autopsies, allowing students to assist in autopsies, including forensic pathologists encouraging medical officers to perform autopsies if needed, and drawing the attention of students to the emotional aspect during the experience, a group of local academics in forensic medicine recommended. These suggestions were made in an original research paper on the “Perceptions of medical students on the autopsy and its significance as a teaching-learning method” which was authored by D.H. Edussuriya (Professor in Medical Education at the Peradeniya University’s Forensic Medicine Department), P. Paranitharan and W.N.S. Perera (both attached to the Kelaniya University’s Forensic Medicine Department), M.G.N.I. Thilakarathne, W.M.S.Y. Wijesiriwardena and C. Nanayakkara (all three attached to the Peradeniya University’s Forensic Medicine Department), and published in the Sri Lanka Journal of Medicine 30 (1) in July, 2021. Background In Sri Lanka, all medical officers are required to attend to medico-legal work independently, including the conducting of autopsies. Therefore, forensic medicine is a compulsory component in the Bachelor of Medicine, Bachelor of Surgery (MBBS) programme. It is taught in the para-clinical years with a compulsory clinical appointment including autopsy exposure. The advantages and benefits of autopsy exposure during the undergraduate period go beyond the development of the skills of dissection, as it helps in learning anatomy (L.S. McNamee, F.Y. O’Brien and J.H. Botha’s “Student perceptions of medico-legal autopsy demonstrations in a student centred curriculum”), pathology, gaining emotional confidence as a career skill, as a research and study tool, diagnostic and communication skills (A.R. Bamber and T.A. Quince’s “The value of post-mortem experience in undergraduate medical education: Current perspectives”), and helps develop emotional strength and empathy towards the victims and the relatives. However, Edussuriya et al. noted that there is a tendency worldwide towards making forensic medicine a postgraduate discipline with minimal exposure to autopsies during the undergraduate period. In the Peradeniya University’s Medical Faculty, the clinical appointment in forensic medicine is of four weeks duration and the students are expected to observe and assist in post-mortems, as well as document medico-legal examination forms, medico-legal reports, and cause of death forms. The intended learning outcomes of the clinical appointment indicate that conducting a post-mortem examination under supervision, performing relevant investigations and referrals, describing procedures in dissection, and preparing a post-mortem report for submission to court are essential skills that need to be acquired.  An objective, structured, practical examination is conducted at the end of the clinical appointment and the overall clinical knowledge regarding forensic medicine including autopsy related knowledge is evaluated. In the Kelaniya University’s Medical Faculty, students are able to observe and assist post-mortem examinations during the forensic medicine clinical appointment. Students are expected to observe a minimum of five different post-mortem examinations.  Moreover, they should assist and clerk at least one post-mortem examination and they are encouraged to witness as many medico-legal autopsies as possible, preferably of different varieties, which will improve the skills of compiling a report which includes a brief history, examination findings, cause of death, samples taken for further examination, and the relevant opinion. It is considered compulsory for the completion of the two weeks clerkship. Bamber and Quince revealed that teachers and students are in agreement that autopsy-based teaching has many potential benefits including a deeper understanding of end-of-life issues, medical fallibility, and clinical knowledge, and emphasised that students gain most benefits from repeated attendance at autopsies being taught by enthusiastic teachers.  Edussuriya et al. sought to determine the perceptions of medical students regarding the autopsy and its significance as a teaching-learning method. Study Data was collected from a group of medical undergraduates of the Medical Faculties of the Universities of Peradeniya and Kelaniya. A questionnaire on their perception of the autopsy was administered to medical students who had completed the forensic medicine clinical appointment. The students’ perceptions were divided into four main categories – cognitive, emotional, societal, and general. Of the 305 students who responded to the questionnaire, 206/67.5% were from the Peradeniya University’s Medical Faculty while 99/32.5% were from the Kelaniya University. In terms of gender/sex, 189/62% were female and 116/38% were male. All the students were over 24 years, while a majority (58%) were between 26-27 years of age. With regard to ethnicity/race, 92% were Sinhalese, 5% were Muslim, 2% were Tamil, and 1% were from other ethnicities. Concerning religion, 263/86% students were Buddhist, 19/6% were Christian, 16/5% were Islamic, and 1% considered themselves as not having a religion. The cognitive aspect Overall, the students had a positive perception of the cognitive impact of the autopsy. A majority (260/85%) either agreed or strongly agreed that the autopsy helped refresh their anatomy related knowledge, while 36/12% remained neutral. Over 95% either agreed or strongly agreed that they appreciated the actual morphology and pathological changes of the human organs after autopsy exposure.  A total of 86% appreciated the fact that they gained an understanding of the clinico-pathological correlations while 84% said that they became familiar with death certification during the process, and 86% thought that the visual and emotional nature of the autopsy makes it a memorable learning experience.  The emotional aspect A total of 195/64% felt saddened by the death and empathised with the family, while 94/31% remained neutral and 15/15% were not saddened by the death, and nor did they empathise with the bereaved family. Of those who were neutral or did not empathise, the majority (62/56%) were male. Even though 73% felt uncomfortable with the nauseating smell at the autopsy, the majority (77%) did not feel uncomfortable about seeing blood, and only 23% were distressed with the dissection of the bodies.  The students were divided on their opinion regarding the fear of exposure to the autopsy and the mortuary before the experience, where 146/48% disagreed or disagreed strongly and 108/36% agreed or agreed strongly. A total of 85/28% who agreed or strongly agreed that they were scared before the exposure were female.  A total of 53% were not comfortable during the first post-mortem exposure. However, a slightly higher percentage (57%) agreed that the exposure to the autopsy made them mentally and emotionally stronger. The societal aspect The majority (229/75%) disagreed that the autopsy is disrespectful. However, only 45% stated that they would consent to an autopsy of a friend or relative if the need arises. General A total of 68% agreed that they should witness more autopsies, while 77% agreed that students should assist in dissections at the autopsy. Only 12% felt that they would not watch an autopsy if given the choice. A total of 91/30% were neutral and only 101/33.1% agreed that they would not mind performing autopsies as medical officers. “There is no doubt that the autopsy is a positive teaching-learning experience for medical students and that it helps to advance different learning styles and maximise all the dimensions such as the cognitive, emotional, societal, and general aspects,” noted Edussuriya et al.  Benefits of med students’ participation in autopsies Edussuriya et al.’s study showed that medical students appreciate medico-legal autopsy demonstration as a positive learning experience due to its visual and emotional nature. Although the primary aim of these autopsies was to teach forensic medicine, most students found them helpful for learning anatomy and for the clinical and pathological correlation.  However, the lack of empathy or the neutral attitude of a significant proportion of the students towards the next of kin highlights an important aspect that is being neglected during this teaching-learning experience, Edussuriya et al. observed, adding that the emotional aspect of this process must therefore be emphasised by the teachers not only to enhance the learning experience but also to develop skills such as empathy, communication, breaking bad news, etc. The fact that a significant proportion claimed that the exposure to the autopsy made them mentally and emotionally stronger and the fact that a significant proportion still felt uncomfortable due to the blood, smell and dissection during the process highlights, according to Edussuriya et al., the fact that more autopsy exposure may be required.  Even though a majority of the students disagreed that the autopsy is disrespectful, only 45% would consent to an autopsy of a friend or a relative if the need arises. Edussuriya et al. emphasised that it is necessary to explore the reasons for this reluctance in order to create an environment where autopsies may be performed freely, which would not only bring closure to the relatives and ensure justice, but would also help in the advancement of the discipline.  Medical students considered that the visual and emotional nature of the autopsy makes it a positive learning experience in terms of learning anatomy and pathology. They felt that they should witness more autopsies and should assist in dissections at the autopsy. However, a significant proportion was not sensitive to the emotional nature of the experience. The majority of students were not comfortable in the autopsy environment and process, and stated that they would not consent to an autopsy of someone close to them if the need arose.   


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