SEARCH

SEARCH BY CITATION

Keywords:

  • curriculum;
  • perception;
  • attitude of health personnel;
  • autopsy/*legislation & jurisprudence/psychology;
  • education, medical, undergraduate/*methods;
  • teaching/*methods;
  • students, medical/*psychology;
  • forensic medicine/*education

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. References

Objectives  Teaching autopsies in undergraduate medicine, although traditionally considered valuable by both educators and students, have been marginalised in modern curricula. This study explored medical students’ experiences of the medico-legal autopsy demonstrations which formed part of their training in forensic medicine.

Methods  In this phenomenological study, qualitative data obtained by interviewing 10 Year 4 medical students from various socio-cultural backgrounds were interpretively examined. One-to-one, semi-structured interviews were tape-recorded and transcribed. The data were thematically organised and then analysed using a theoretical framework of three dimensions of learning, namely, cognitive, emotional and societal.

Results  Students still perceive autopsies as essential even in the context of self-directed learning. They identified a better understanding of anatomy and traumatology as the main cognitive benefits. At an emotional level students felt they had developed a degree of clinical detachment and would be better equipped to deal with issues surrounding death. Although socialisation influenced students’ feelings about the autopsy, it did not detract from their appreciation of the educational value of the experience.

Conclusions  The results support previous findings from both students, prior to curriculum reform, and medical educators who were canvassed for their opinions in relation to a modern curriculum. Besides the obvious cognitive advantages, educators should be mindful of the hidden curriculum that emanates from autopsies because it impacts on the development of professionalism and ethical behaviours of future medical practitioners.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. References

Autopsy has long been an important part of the medical curriculum.1–4 However, there has been a gradual marginalisation of the practice in progressive adaptations of medical curricula. Indeed, even cadaveric dissection in anatomy and autopsies in anatomical pathology appear to have been squeezed out to accommodate the overall decrease in training time and to allow more time to be allocated to multidisciplinary themes.5–7 Besides curriculum reform, technological alternatives such as videos and CD-ROMs,8,9 the general decline in hospital autopsy rates1,8,10,11 and prevailing legislation11,12 have all contributed to the declining use of the autopsy as a teaching tool.

Despite this marginalisation in modern curricula, educators still consider the autopsy important in conveying appropriate knowledge and attitudes to modern doctors.8 It also delivers significant elements of the ‘hidden curriculum’.13 In the past, students have also recognised the necessity of autopsies to medical education.1–4,14 However, most studies on the subject were conducted before curriculum reform and used survey questionnaires to collect data in a normative scientific research methodology. They did not explore in depth the how and why associated with learning that takes place. In the light of andragogical principles15 which value the learner’s life experience, and given the integrated nature of new curricula, it becomes necessary to re-evaluate the nature of learning experiences on offer and how they relate to the curriculum as a whole, rather than limiting their relevance to a particular specialty.

Accordingly, a study was undertaken to determine how medical students experience medico-legal autopsies, which are used as a teaching strategy in forensic medicine. The term ‘medico-legal’ in this context applies to all autopsies of subjects whose deaths are deemed unnatural (including cases of sudden unexpected deaths where a medical practitioner is unable to certify natural causes). The Inquest Act 58 of 1959 (South Africa) makes provision for medico-legal autopsies to be performed by state-employed doctors, where consent of relatives is not a legal requirement. Persons who may be present during an autopsy are also regulated by this Act, which stipulates that the police investigating team and other persons who have a substantial or peculiar interest in the matter may be present with permission from either the magistrate or the doctor performing the autopsy.16 Medical student observers are included in the latter category for training purposes. Hospital autopsies, as elsewhere, have become a rarity and therefore can no longer be used for undergraduate medical training. Although forensic medicine teaching may have all but disappeared from undergraduate medical curricula elsewhere, exceptionally high levels of violence, crime and road traffic accidents in South Africa necessitate teaching the subject at undergraduate level. All medical practitioners need to be aware of their medico-legal and ethical obligations towards patients with trauma-related injury, whether the patients are still alive or deceased. Therefore, medical students at the University of KwaZulu-Natal take a course in forensic medicine in their fourth year of study. Methods of delivery include lectures and case-based tutorials which cover most of the course content; the practical application of concepts is consolidated at the autopsy demonstrations central to this study.

Classes of approximately 200 students are divided into four groups, each of which attend four autopsy demonstrations in a modern hospital mortuary. In the cases viewed by this particular study cohort, causes of death were a stab wound to the chest, a gunshot wound to the head, a motor vehicle accident (to a pedestrian) and hanging. Students viewed autopsies from behind a glass partition while a foot pedal-controlled camera system projected close-up images of wounds and macro-pathology, as required, to strategically positioned television monitors situated throughout the viewing area. Communication between the pathologist conducting the autopsy and students was via microphones. Occupational health and safety considerations are paramount in an environment where the prevalences of human immunodeficiency virus (HIV) and tuberculosis (TB) within the general population are as high as they are in South Africa.

The study addressed the following questions:

  • • 
    Did students perceive autopsy demonstrations as benefiting their learning; if so, what was the nature of the benefit?
  • • 
    What were their experiences of the demonstrations? (How did they feel about the autopsy process?)
  • • 
    What factors did they believe affected their experiences?
  • • 
    What concerns or objections did they have about the use of autopsy demonstrations for teaching?
  • • 
    What recommendations would they make for future curriculum planning?

Methods

An inductive phenomenological approach was chosen over the traditional positivist methodology because phenomenology explores an individual’s experience of a particular phenomenon.17 The study was inductive in that it did not attempt to prove or disprove a particular hypothesis. It did, however, utilise a theoretical framework of learning to guide the gathering and analysis of student perceptions of autopsy demonstration experiences. Such usage of an existing theoretical framework is the norm18 in most qualitative research designs other than those employing grounded theory methods.19 The theoretical framework comprised the three dimensions of ‘cognition’, ‘emotion’ and ‘society’ described by Illeris as constituting the tension field of learning.20 The two internal psychological dimensions, cognition and emotion, are directly integrated, as thoughts are always impacted by emotion, whereas feelings are always affected by cognitive influences. Together, they have a reciprocal relationship with the social-societal (external) dimension, as depicted by Illeris in Fig. 1.

image

Figure 1.  Interaction between the dimensions in the tension field of learning (Illeris, 2004, p 118)

Download figure to PowerPoint

Illeris’ theory was selected for this study as it offered a broad, holistic framework which, it was believed, more closely approximated reality than did one which confined its focus to just one or two of these dimensions. In addition, this framework was likely to incorporate all possible findings.

Data collection and analysis

Ten students were purposively selected from the one student group that had completed viewing of autopsies at the time the data were collected. The selection aimed to capture as broad a range of ethnicity and gender characteristics as were present in the study cohort. This was deemed preferable to inviting volunteers to participate, a process which might have resulted in our hearing only the views of students with the same characteristics. The characteristics of the participants are detailed in Table 1. All the selected students consented in writing to participate after written details of the study had been communicated to them.

Table 1.   Demographic details of students participating in the study
Ethnicity and genderNumberAge, yearsPrevious qualification (if any)
African, male324, 24, 26 
African, female322, 34, 391 Bachelor of Nursing 1 Bachelor of Science
Asian, female222, 22 
Asian, male121 
White, female1281 Bachelor of Nursing

Individual, semi-structured interviews of 35–45 minutes were conducted with each of the 10 students in an office within the Department of Forensic Medicine. Students scheduled appointments at times convenient to them, ranging from 2 days to 4 weeks after the last autopsy demonstration. The more general and ‘non-threatening’ questions were posed first. Table 2 outlines the interview schedule, which allowed for probing of the participants’ initial responses.

Table 2.   Interview schedule (outline)
Introductory conversation
Thanks, purpose of study, permission to tape etc
Context and background of participant:
Age, race and sex of participants
Educational value derived by the student:
Were the autopsy demonstrations of benefit to your learning? In what ways?
Experience of demonstration:
How did you feel about attending autopsies? (before, during, after, first and subsequent autopsies)
Factors affecting their experience:
Preparation, beliefs, previous experience of trauma or death of friend or family, environmental factors etc
Conclusions and recommendations
Do autopsies have a role in teaching medical students?
Do you have any objections, concerns, recommendations?

Interviews were audiotaped and transcribed verbatim. Each transcript was then read carefully and coded (i.e. given descriptive labels). Thereafter, codes were arranged according to the research questions and sorted into categories using the qualitative research tool NVivo Version 2 (QSR International Pty Ltd, Doncaster, Vic, Australia). This enabled the checking of relationships between categories so that key themes could be identified. These in turn were organised according to the dimension of learning (cognitive, emotional, societal) that appeared most relevant for meaningful display of the data. These activities constituted the data reduction, display and conclusion drawing elements of a qualitative analysis process described by Miles and Huberman.21 Any apparent explanations or patterns of causality were checked and rechecked against the original transcripts (i.e. the raw data). In this way, the meanings emerging from the data were tested for their plausibility and confirmability (validity or trustworthiness). All interviews and data analysis were carried out by the principal author, who was known to students as the technical co-ordinator providing student support for the programme, but who had no role in their formal training or assessment.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. References

The main findings have been grouped into three areas, namely:

  • 1
    explicit benefits to learning: the cognitive dimension;
  • 2
    experience of autopsies: the emotional dimension, and
  • 3
    external influences: the societal dimension.

Some general student opinions have also been reported. This arrangement facilitates correlation of the results with the key research questions of the study.

Explicit benefits to learning: the cognitive dimension

Learning anatomy was a very important aspect for many students and often the first benefit they mentioned (cited by 6/10 students). Some of these students specified the dissection of the head and brain as particularly beneficial to their learning (4/10):

‘It was interesting… [when] we did anatomy we never did dissection, so we’d never actually seen the organs…and how it would actually look in a cadaver…’

‘…when you go to dissecting hall [in earlier years of study], you only observe what is already dissected…even the structures of the brain…it [autopsy] helped in anatomy...’

‘…but I never knew that the whole head is occupied by the brain itself…because I never saw the skull of a human being anywhere opened.’ [Respondent thought the cerebrospinal fluid occupied more space.]

Students felt that the autopsies had helped them to distinguish between non-natural and natural causes of death and to have a better understanding of the various mechanisms of death (7/10). This was extrapolated to a realisation that they would be better equipped to complete death certificates in their future practice:

‘…about the clinico-pathological correlation [when reading it], it did make sense, but not as much as when I witnessed it...’

‘…obviously [we are] going to be in a position where you are going to some day sign on that death certificate form [to] say whether somebody died of a natural or unnatural death… so I think it’s important to recognise what those are and you can make a decision based on total objectivity…’

‘…you almost get to think the whole process through... I think it definitely helps you with your officially formulating a death certificate.’

Seeing injuries on the cadavers was appreciated by students as it helped them learn the correct terminology for describing wounds resulting from different types of trauma (8/10). For example, blunt or sharp force injuries and patterns of injury typically found in motor vehicle accidents were mentioned:

‘….wound descriptions…like tissue bridges [in lacerations] and incisional wounds you actually see it… and understand the pathology behind it…’

‘We actually saw how the bumper fractures are caused, how they look…’

Observing the macropathology first-hand gave some students a better understanding of the extent of injuries (5/10). Pallor of the viscera, for instance, became recognisable as they repeatedly observed their appearance post exsanguinations:

‘…[the victim was] stabbed on the left [pointing to the chest], how far the knife…travelled… Even in a real patient, I’ll have a better understanding…[of] what may be happening inside…’

‘…and the pelvic injury [I realised] how much blood can actually accumulate in the pelvic region itself...’

‘…in terms of hypovolaemia, the third autopsy it was more obvious, the paleness…’

Students (4/10) reported that knowledge of the actual autopsy procedure and the various investigations that can be performed gave them insight into why things were done in a certain manner:

‘…learnt a lot in terms of the investigations that could be carried out…’

‘I learned [that] when you [are] taking alcohol, you take it peripherally, and why…’

An awareness of the fallibility of medicine was raised as the autopsy represented an opportunity to learn from mistakes (1/10):

‘Medical value? ...I would think so, because there are so many unexplained things in the medical field that, maybe academically, after an autopsy you’ll be able to know what wrongs have been done, as a doctor what did you do wrong, and that way you could…improve.’

The puzzle-solving nature of autopsy teaching seemed to reinforce problem-based thinking (2/10):

‘…to see X, Y or Z and then to think of or postulate what caused X, Y or Z… that’s where the autopsy came in…’

Experience of autopsies: the emotional dimension

All participants had a definite sense of ‘looking forward’ to autopsies, especially the first one, although they used various terms (‘excitement’, ‘curiosity’, ‘mixed feelings of anticipation and dread’, ‘interested’, ‘intrigued’) to describe this:

‘How they were going to open the body was something I couldn’t imagine… it was quite…amazing…’

‘Wow, so this is what it really looks like… I was excited…’

Regardless of their age and whether they had had any prior experience with death, students felt a degree of discomfort with the dissection process (10/10), particularly of the head (3/10). Their descriptions of their feelings included words such as ‘anxiety’, ‘dramatic’, ‘scary’, ‘prickly’ and ‘fear’:

‘Beforehand I thought I’d be OK… but when we actually saw them cutting into the patient and I saw him open, it was quite…[uncomfortable]…’

‘…but the first time it was quite jarring when they cut open the head…’

Discomfort was greatest at the first autopsy, where most students were unable to concentrate on any teaching other than the dissection (8/10). However, through a degree of ‘desensitisation’, which had set in by the second autopsy, they were able to concentrate on other aspects:

‘…the first postmortem I sat there… I didn’t take any notes. But those postmortems that followed… I began to take notes and concentrate...’

‘…they do have an important role… desensitise you so you are able to deal with the wounded…’

‘…it’s not a good thing to go to the family crying, trying to tell them how you feel, what happened…’

To a few students, however, the body even became ‘objectified’ and they felt no emotional involvement after the first autopsy (3/10):

‘…it sounds quite harsh but, you tend to forget about the person, it sort of becomes a specimen on the table… after that the emotional aspect went away.’

Students who allowed themselves to reflect on a deeper level claimed to have fostered attitudes of respect, empathy and compassion (5/10):

‘….based on my previous experience as a nurse, I’ve attended to many relatives who’ve lost their loved ones… but now… I think it’s more meaningful and there’s more empathy involved… and compassion.’

As illustrated in several of the quotes above, participants were clearly motivated by thoughts of their future practice as doctors.

External influences: societal dimension

The students described themselves as Christian (6), Hindu (1), Muslim (1), ‘New Age’ (1) and of African Traditional Religion (1). All except one (a male nominal Christian) believed in life after death. One (a female Muslim) explained that, although not forbidden, autopsies do not sit comfortably with Muslim beliefs and rites of passage. However, she appreciated the purpose of autopsies and did not advocate their replacement with alternative teaching tools. None of the other religious persuasions presented a direct objection. Even those with traditions of animism (3/10) were satisfied as long as all organs were returned to the body post-dissection.

Although concern for those who might be ‘psychologically vulnerable’ or ‘overly squeamish’ resulted in a reluctance to say that autopsy viewing should be compulsory (3/10), students felt that all medical practitioners should attend at least one autopsy in order to appreciate the procedure and be able to address the concerns of the deceased’s family (4/10). One participant pointed out that ‘students may not realise the importance of something [in the curriculum] till it’s gone’.

Exposure to forensic pathology was appreciated (4/10), even if it meant being dissuaded from following a career in pathology (1/10). Observing the process also helped dispel misconceptions passed on by lay communities regarding the handling of bodies and viscera (1/10):

‘…we used to be informed… people in the mortuary normally take the inside organs out and… bury them outside the body… With the autopsy, I realised what is actually done… and why.’

Autopsies prompted participants to reflect on their own mortality (2/10) and on social links and circumstances surrounding the deceased person (4/10):

‘I won’t mind where I am buried… because that’s just the body… because I know my spirit, that’s the important thing…’

‘…that man was very healthy… I felt “What a waste”… The old lady who was involved in an MVA [motor vehicle accident], I felt sorry for… maybe because of old age she couldn’t run as quickly…’

General student opinions

Most students preferred the impact of viewing autopsies on a real, fresh cadaver (8/10) and insisted that absolutely no alternatives (videos, virtual autopsies or computer images) would be acceptable. Two students, however, felt that viewing autopsies on a television screen would have been equivalent.

Several participants emphasised that they would rather have stood next to the dissecting table (5/10), whereas others were not completely convinced of the need for this (2/10) and the rest were grateful for the solid glass partition (3/10).

As long as the spectrum of trauma observed could be varied, viewing three or four autopsies was thought to be adequate (10/10). A few students (2/10) felt that they should be better prepared by, for example, detailed prior explanation.

A hypothetical situation where a body might be known to student(s) was the primary cause for concern (3/10). Students were generally satisfied that bodies were handled with due respect (10/10), although some thought it callous that the brain tissue was returned to the chest or abdomen rather than the cranium (2/10).

The main findings are summarised in Table 3.

Table 3.   Summary of key findings
Explicit benefits to learning (cognitive dimension)
Understanding anatomy
Mechanisms of death and death certification
Trauma pathology and terminology
Forensic investigations and procedures
Fallibility of medicine
Problem-based thinking
Experience of autopsies (emotional dimension)
Anticipation
Discomfort
Desensitisation to, hardening, objectifying of the body
Respect, empathy, compassion
Motivated by future practice
External influences (societal dimension)
Belief systems or religious convictions
Individual preferences or professional priorities
Exposure to field – forensic pathology
Reflection – own mortality, social links to deceased
General student opinions
Real cadaver preferred over virtual alternatives
Opportunity to stand next to dissecting table
Preparation prior to autopsies
Variation of trauma pathology
Adequate number of cases
Deceased person might have been known to student(s)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. References

This study showed that medical students still appreciate the medico-legal autopsy demonstration as a learning experience. This finding was consistent with student views evaluated prior to recent curriculum reform and using quantitative methodologies.1–4,14 Although qualitative data sourced from interviews with a small sample lack generalisability, they do have certain strengths compared with questionnaire-based research. For example, they preserve the chronological flow between events and consequences, making it possible to derive meaningful explanations.21 Autopsies were also viewed as valuable by medical educators in Burton’s phenomenological study.8 Whereas Burton8 comprehensively described the intended curriculum, the present study explored students’ perceptions of their reality, and thus represents the received curriculum.

Although the primary aim of these autopsies was to teach forensic medicine, most students found them helpful for learning anatomy. This was not unexpected as the study cohort had not dissected a cadaver during anatomy training. It suggests that anatomy teaching could be incorporated at the first demonstration when students’ concentration was restricted mainly to the dissection. Students therefore agreed with medical educators, who felt that autopsies were under-utilised for teaching in general and anatomy teaching in particular.8

Regarding intended learning outcomes, students felt that they had understood more about trauma pathology and the associated mechanisms of death. The correlation of theory with practical application and familiarisation with macro-pathology were significant learning processes inferred. Students also recognised a variety of implications for their future medical practice. This is consistent with the concerns expressed by Jones, a final-year British student, who identified deficiencies in training in medico-legal matters, which he attributed to the general decline of forensic medicine in undergraduate curricula.22 Despite the fact that the literature indicates that forensic autopsy rates, worldwide, remain fairly constant,10 there is little mention of their use in undergraduate medical training. The reasons for this may be complex, but the area seems worth investigating.

Beyond overt cognitive benefits, autopsies delivered a considerable hidden curriculum regarding the development of professionalism and attitudes of respect, empathy and compassion. These covert learning aspects, which are more ‘caught than taught’, were found interspersed throughout the data. For example, the ‘desensitisation’ resulting from the first autopsy cannot be taught, but indicates the development of resilience for future encounters with wounded and dying patients, and for dealing with their family members. The negative possibility that some students might be led to objectify the body8 was confirmed, albeit by a minority of students. Although medical educators had considered awareness of the fallibility of medicine and problem-based thinking to be obvious benefits,1,13 these were mentioned infrequently by students in this study.

The socialisation of individual students played a role in their reflective practice.23 Many of the factors that influence covert learning seem beyond the control of educators, such as prior learning (including life experience), cultural or religious beliefs, conceptualisations of learning, interests and psychological predispositions. However, an awareness of the complex interplay of emotions and reflection that underlies learning from autopsies should be advantageous if the attitudes of future practitioners are to be influenced whilst they are being formed.1,4 Also to this end, tutors should make the benefits of autopsies more explicit and highlight the relevance of the procedures demonstrated for students who may not reach these conclusions. The inclusion of timetabled opportunities for reflection by students is also suggested in order to take advantage of different learning styles and to maximise all three dimensions of learning, namely, the cognitive, emotional and societal.20

All students held positive attitudes towards their learning from autopsies and most expressly felt that no virtual alternatives would be acceptable. However, virtual tools might be useful in conjunction with at least one real autopsy, especially where severe logistical constraints exist. Where contextual parameters permit, better preparation for autopsy viewing, including prior learning experiences in earlier years, is recommended.

Burton has suggested that each institution needs to weigh the benefits of autopsy-based teaching against its negative aspects within the context of its own curriculum.8 Although this is indeed the case, the present study clearly showed student support for the inclusion of this teaching strategy in a current student-centred medical curriculum.

Contributors:  LSM planned and carried out the research project in part fulfilment of an MEd degree. This paper represents a condensed report of selected aspects of the study and was written by LSM. FYO’B supervised the research project, and guided the research process and interpretation of the data within a relevant theoretical framework. JHB critically evaluated the data and assisted in the preparation of the paper. All authors approved the final manuscript for publication.

Acknowledgements:  the authors are grateful to the participating students for their time, honesty and enthusiasm and to Professor S R Naidoo, Department of Forensic Medicine, University of KwaZulu-Natal, Durban, South Africa, for supporting the study.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  this study was approved by the Research Office of the University of KwaZulu-Natal (approval no. HSS/061784).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. References