The autopsy experience
Medical students report on seeing their first post mortem
- By: Isobel Weinberg
Have you witnessed an autopsy? The answer will depend on the curriculum at your medical school and the optional modules you have chosen. Opportunities to see an autopsy vary between medical schools. One thing, however, is certain: it is much less common for students to observe autopsies in than it used to be.
Indeed, autopsies in general are in decline. Autopsy rates have fallen over the past 40 years in the UK, US, and New Zealand. Why is this? It might be because are fewer uncertain causes of death thanks to improved diagnostic technology; because relatives often decline consent; and because doctors are increasingly less likely to recommend autopsies to the relatives of a deceased patient—perhaps because they do not see them as important, or because they struggle to justify them to the relatives. Yet, 48% of autopsies provide extra information above clinical findings. And, despite the improvement in diagnostic technology, the rate of discrepancy between premortem and postmortem diagnosis has shown little improvement over the past 75 years.
Alongside this decline, the requirement for medical students to attend an autopsy has also dropped off. At the start of the 20th century, medical students not only routinely attended autopsies but learnt to conduct them. Now, most medical students in the US graduate without seeing a post mortem, and less than half of US medical schools make attendance at one compulsory. Indeed, in 2002, students in Auckland, New Zealand, were banned from attending autopsies, after a scandal over the discovery that paediatric hearts had been removed at autopsy and kept for teaching purposes without consent.
Are students missing out on a valuable educational experience? Plenty of research indicates that medical students find attending post mortems helpful. One survey showed that students found they learnt not only about anatomy and pathophysiology, but also legal proceedings and public health, and gained a greater appreciation of medical uncertainty and of grief. But then, research written by pathologists would say that. Surveying students to find out whether they regard the experience as worthwhile produces more varied responses. They tend to have mixed opinions over whether it should be compulsory to attend an autopsy. In one study, although many students reported autopsies to be educationally useful, nearly 20% described a feeling of great distaste. One student described it as “one more step along the path of losing your natural feelings as a doctor.”
With this divided background, we asked Student BMJ readers who had seen post mortems to tell us about their experiences. For some, the experience had been a compulsory part of the course, whereas others had had to work hard to arrange it themselves. Distaste certainly features heavily in the responses. “Overall, I thought the experience was helpful though I would still prefer learning from a preserved body to avoid the pungent smell of decomposition and bodily fluids,” said Shujing Jiang, a second year medical student at King’s College London. “The vivid colours, slippery textures, and nauseating squelching noises from the body were very different from the preserved cadavers in dissection,” said Tanya Dhir, a second year medical student at King’s. But, despite this, overall the responses were positive about the value of post mortems as a learning experience. “I didn’t enjoy the post mortem, but it was a good learning experience—not necessarily medically, but for personal development. It left me with a stinging sense of my own mortality,” said Tanya Dhir, a second year medical student at King’s College London.
Have you seen an autopsy? If not, maybe you should.
Sarah Hallett, fifth year medical student, University of Nottingham
At my university, all students must see at least one post mortem as part of our pathology teaching in the first year of the clinical phase. I wasn’t particularly concerned about the prospect; I had found working with cadavers during my dissection tutorials surprisingly stress free. What I didn’t anticipate, however, was how knowing the history of the case would affect me emotionally.
A middle aged man had hanged himself. When he was brought in, I was taken aback: he looked so young, and could have been just asleep if it wasn’t for the livid ligature mark around his neck. The technician told us about the events in this man’s life that had led up to this point in a matter of fact way, as he went about cutting him open, cracking the chest, and removing, weighing, and slicing organs with startling speed. He pointed out the findings as he went along, which we would later write up in a clinical-pathological correlation and reflection exercise.
I still think seeing post mortems are an important and useful part of the course, but the combination of the seemingly careless examination and the tragic story left me shaken for the rest of the day.
Tamoghna Biswas, medical intern, Medical College Kolkata, India
It was my sophomore year at medical school. Bustling with enthusiasm, we had started our forensic medicine classes. We were told that as a part of our curriculum, it was mandatory to attend a few postmortem sessions. So, one morning, a few of us, accompanied by our instructors, went to the police morgue attached to our college.
What struck me at the first encounter was the stench, which persisted despite copious amounts of air fresheners. The stink made some of us nauseous. Our faculty told us about putrefaction, how it happens quicker in tropical countries, and how it helps determine the time since death.
Lined up for the day was a case of death caused by suspected copper sulfate poisoning. After the official protocol of identification and receiving the preliminary history from the police authorities, the pathologist started the dissection while we observed. We learnt about the types of incisions that can be used, the sequence of examination in an unknown poisoning, and the signs to look for in copper sulfate poisoning. We learnt how to identify rigor mortis and where to look for hypostasis. Other important lessons that day included viscera labelling and preservation techniques in poisoning cases.
The essence of autopsy is deconstruction and finding clues; clues that lead to the bigger pictures like the cause and the time of death. In that short session of two hours, we could learn only a few things, it was more of an orientation session for future classes. The experience was not as gruesome as I had anticipated it to be, rather it was exciting and enriching. I have attended many postmortem sessions after that, but as they say, “you never forget the first post mortem you see.”
Yassar Alamri, MBChB/PhD student, University of Otago, Christchurch, New Zealand
Post mortems can be a double edged sword. On the one hand, they can be highly educational and valuable experiences, presenting an excellent chance to observe human anatomy in a non-embalmed state. On the other hand, however, they can be a distressing experience to some students for a variety of reasons. Pathologists and technicians must sometimes go through a few post mortems in one day. Even though all cadavers are handled with care and respect, it is not the usual gentleness medical students have grown accustomed to in patient care. Ribs are cracked, the scalp is stripped off and skull opened, and the thoracoabdominal cavity is eviscerated in a matter of minutes. This can appear, as one student puts it, “brutal.”
My experience from the single post mortem I attended in my fourth year was mixed. I found it fascinating that the pathologist was able to tell whether the person ate vegetables from the colour of their fat tissue. We were able to see fluid in the lungs, which was part of the cause of death. With that said, however, I could not help but feel sad. The person had taken their own life, which made the experience even more gruesome than usual.
Ashwin Singh Parihar, final year medical student, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar, Uttarakhand, India
In India, we have compulsory medico-legal postmortem sessions in the second year of our medical curriculum as a part of forensic medicine. Despite the initial gruesome feelings towards it, our first postmortem session turned out to be quite an informative one.
We were shown the various signs that helped one to ascertain the manner of death, how apparently suicidal cases turned out to be homicidal, how one could determine the probable time since death and much more. We, as second year students, were taught the basics of identifying the mode of death, toxicological factors that could be related to it, and most importantly, how to carry out a thorough inspection so as to not let the tiniest clue escape.
After the end of our second year course, we were glad the postmortem postings were mandatory. They helped us understand a lot of practical medico-legal stuff with ease.
Amy Goodman, third year medical student, Keele University Medical School
As part of our second year pathology experience, we had the opportunity to attend at a post mortem. These sessions were an excellent teaching resource, giving students an appreciation of three dimensional anatomy before starting their clinical years. It also supplemented my pathology learning with clinical context. Most importantly for me, I found it valuable to see that it is normal for patients to sometimes not respond to treatment. I observed a post mortem on a patient who had died from a routine surgical procedure after refusing a blood transfusion because they were a Jehovah’s Witness. This not only let me come to terms with death, but also to understand how different patient perspectives can affect prognosis.
Competing interests: None declared.
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Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2012;20:e7847
- Published: 11 December 2012
- DOI: 10.1136/sbmj.e7847