JOURNALOF PATHOLOGY, VOL.
162: 187-1 88 ( 1990)
EDITORIAL WHY SHOW AUTOPSIES TO MEDICAL STUDENTS? Autopsy demonstrations were a central part of medical undergraduate education in major European centres throughout the nineteenth century and the first half of this century, and became widely used in the United States of America following the influential Flexner report of 19 10. Organ demonstrations were a central part of life in medical schools, with good attendance from both students and qualified clinicians.’ In the second half of this century, in contrast, interest in the teaching autopsy has waned to such a degree that students in many medical schools can qualify without watching an autopsy, and without seeing any fresh autopsy material at a11.’ This diminution in interest has occurred in parallel with, and may have contributed to, a widespread and lamentable drop in autopsy rates.’ Some schools have succeeded in giving autopsy demonstrations a modern gloss, particularly with closed-circuit television and video recordings, but autopsies still have a low profile in current medical education. There is no clear consensus about why we should show autopsies to medical students, and there is little information about whether we achieve anything by doing so. The overt justification for autopsy demonstrations, of course, is to teach students about the lesions and diseases revealed in particular examinations, and to allow students to observe the ultimate investigation of patients whom they have clerked. These are entirely laudable reasons, and are in keeping with the piecemeal nature of practical clinical experience on the wards. However, low autopsy rates, competition for students’ time from other disciplines, and the increasing complexity of the knowledge that students have to assimilate have made it unrealistic to expect autopsies to provide more than a relatively small supplement to other modes of pathology teaching. What, then, justifies their retention in modern teaching programmes at all? First of all, students should see pathologists at work, both in the mortuary and in the biopsy report0022-34 1 7/90/ 1 101 8 7 4 2 $05.00 0 1990 by John Wiley & Sons, Ltd
ing room, if we expect them to develop realistic expectations of pathology services when they qualify. Some, we hope, will be stimulated by their experiences to want to become pathologists. Where medical education includes no experience of practical pathology, students may have odd perceptions of the pathologist’s role, and we should not be surprised if they fail to understand how laboratory services should be used or prefer to enter specialities with which they are more familiar. Secondly, students’ attendance in the autopsy room should be used to demonstrate how the autopsy is useful, both to relatives and to society in general. In this medical school, students are ready to agree that the autopsy is ~ a l u a b l ebut , ~ most see only one, and remain lamentably ignorant about any benefits beyond the forensic.’ Exposure to several autopsies would be valuable. Many American academics, both clinicians and pathologists, attribute the reduced autopsy rate, at least in part, to the fact that recently qualified clinicians have so little experience of the autopsy that they are unaware of its potential benefit^.^ Whether we like it or not, most requests for hospital autopsies are transmitted to relatives by very junior clinicians, and a house officer who understands theneed foranautopsy ismorelikely to obtain permission for it than one who has no idea of its value. Finally, demonstrations of autopsy material are an excellent opportunity to introducejunior students to the processes of clinicopathological correlation, differential diagnosis, and the significnce of diagnostic discrepancy. This leads easily into the concept of audit, and provides an excellent opportunity to advertize the autopsy’s role within it. Students are very ready to accept that the autopsy can be used to evaluate clinical performance: and most students attending a single autopsy in our school believed that it had clarified some clinical observations.6 The issue of diagnostic discrepancy is of central and fundamental importance, and it is vital that students should learn to distinguish between inadvertent and inevitable discrepancies, on the one hand, and those
188
EDITORIAL
caused by clinical misjudgement or oversight, on the other hand.'.7 Autopsies provide excellent opportunities for students to be introduced to clinical fallibility, and a sympathetic discussion of clinical error can reassure students that they can become good doctors without having to achieve absolute diagnostic and therapeutic perfection. Some clinicians still foster the illusion of clinical omnipotence, encouraging students by their example to deny medical uncertainty, whereas we should be helping them to accept and cope with it. If the pathologist has difficulty in making a diagnosis in the autopsy room, or finds a discrepancy between a macroscopic interpretation and histological findings, then the illustration of 'necessary fallibility' will be all the more effective.6 Though their role is now very different to the traditional one, teaching autopsies are clearly still important. Unfortunately, we are woefully inept when we try to impart our enthusiasm for them: third-year students in this medical school follow one autopsy in detail, and become much less enthusiastic about personal involvement in autopsies than second-year students who have seen none. It is also disturbing that third-year students would not permit autopsies on their relatives because they have seen the procedure. Third-year students are, of course, in a vulnerable position, and it is possible that their struggles to come to terms with mortality
in general colour their attitude to a procedure that provides the most graphic evidence possible of death and its consequences. Careful and sensitive incorporation of the autopsy into programmes designed to teach students about dying and death might help to reduce students' antipathy to both, and provide the autopsy with yet another indispensible role.
EMYRW. BENBOW Department ofPathologica1 Sciences University ojhfanchester Manchester A413 9PT, U.K.
REFERENCES I . Hill RB. Anderson RE. The Autopsy-Medical Practice and Public Policy. Boston: Butterworths, 1988: 56-64. 2 Anderson RE. Hill RB. The autopsy in academic medical cemers in the United States. Hum Purhol 1988; 1 9 1369-1371. 3. Anderson RE. Hill RB. Epitome. The current status of the autopsy in academic medical centers in the United Statea An1 J Clin Purlid 1989. 92: s31-537. 4. Benbow EW. Medical students' views on the autopsy. J Clin Parhul (in press). 5 . Benbow EW. Autopsy demonstrations to medical students: audit by questionnaire. J Paihul1990: 162 177-180. 6. Benbow EW. A questionnaire survey of the attitudes of second and third year medical students to the autopsy (Abstract) J Parhul 1990; 161: 349A. 7 Anderson RE. Fox RC. Hill RB. Medical uncertainty and the autopsy: occult benefits for students. Hum Parhol 1990; 21: 128-135.
162: 187-1 88 ( 1990)
EDITORIAL WHY SHOW AUTOPSIES TO MEDICAL STUDENTS? Autopsy demonstrations were a central part of medical undergraduate education in major European centres throughout the nineteenth century and the first half of this century, and became widely used in the United States of America following the influential Flexner report of 19 10. Organ demonstrations were a central part of life in medical schools, with good attendance from both students and qualified clinicians.’ In the second half of this century, in contrast, interest in the teaching autopsy has waned to such a degree that students in many medical schools can qualify without watching an autopsy, and without seeing any fresh autopsy material at a11.’ This diminution in interest has occurred in parallel with, and may have contributed to, a widespread and lamentable drop in autopsy rates.’ Some schools have succeeded in giving autopsy demonstrations a modern gloss, particularly with closed-circuit television and video recordings, but autopsies still have a low profile in current medical education. There is no clear consensus about why we should show autopsies to medical students, and there is little information about whether we achieve anything by doing so. The overt justification for autopsy demonstrations, of course, is to teach students about the lesions and diseases revealed in particular examinations, and to allow students to observe the ultimate investigation of patients whom they have clerked. These are entirely laudable reasons, and are in keeping with the piecemeal nature of practical clinical experience on the wards. However, low autopsy rates, competition for students’ time from other disciplines, and the increasing complexity of the knowledge that students have to assimilate have made it unrealistic to expect autopsies to provide more than a relatively small supplement to other modes of pathology teaching. What, then, justifies their retention in modern teaching programmes at all? First of all, students should see pathologists at work, both in the mortuary and in the biopsy report0022-34 1 7/90/ 1 101 8 7 4 2 $05.00 0 1990 by John Wiley & Sons, Ltd
ing room, if we expect them to develop realistic expectations of pathology services when they qualify. Some, we hope, will be stimulated by their experiences to want to become pathologists. Where medical education includes no experience of practical pathology, students may have odd perceptions of the pathologist’s role, and we should not be surprised if they fail to understand how laboratory services should be used or prefer to enter specialities with which they are more familiar. Secondly, students’ attendance in the autopsy room should be used to demonstrate how the autopsy is useful, both to relatives and to society in general. In this medical school, students are ready to agree that the autopsy is ~ a l u a b l ebut , ~ most see only one, and remain lamentably ignorant about any benefits beyond the forensic.’ Exposure to several autopsies would be valuable. Many American academics, both clinicians and pathologists, attribute the reduced autopsy rate, at least in part, to the fact that recently qualified clinicians have so little experience of the autopsy that they are unaware of its potential benefit^.^ Whether we like it or not, most requests for hospital autopsies are transmitted to relatives by very junior clinicians, and a house officer who understands theneed foranautopsy ismorelikely to obtain permission for it than one who has no idea of its value. Finally, demonstrations of autopsy material are an excellent opportunity to introducejunior students to the processes of clinicopathological correlation, differential diagnosis, and the significnce of diagnostic discrepancy. This leads easily into the concept of audit, and provides an excellent opportunity to advertize the autopsy’s role within it. Students are very ready to accept that the autopsy can be used to evaluate clinical performance: and most students attending a single autopsy in our school believed that it had clarified some clinical observations.6 The issue of diagnostic discrepancy is of central and fundamental importance, and it is vital that students should learn to distinguish between inadvertent and inevitable discrepancies, on the one hand, and those
188
EDITORIAL
caused by clinical misjudgement or oversight, on the other hand.'.7 Autopsies provide excellent opportunities for students to be introduced to clinical fallibility, and a sympathetic discussion of clinical error can reassure students that they can become good doctors without having to achieve absolute diagnostic and therapeutic perfection. Some clinicians still foster the illusion of clinical omnipotence, encouraging students by their example to deny medical uncertainty, whereas we should be helping them to accept and cope with it. If the pathologist has difficulty in making a diagnosis in the autopsy room, or finds a discrepancy between a macroscopic interpretation and histological findings, then the illustration of 'necessary fallibility' will be all the more effective.6 Though their role is now very different to the traditional one, teaching autopsies are clearly still important. Unfortunately, we are woefully inept when we try to impart our enthusiasm for them: third-year students in this medical school follow one autopsy in detail, and become much less enthusiastic about personal involvement in autopsies than second-year students who have seen none. It is also disturbing that third-year students would not permit autopsies on their relatives because they have seen the procedure. Third-year students are, of course, in a vulnerable position, and it is possible that their struggles to come to terms with mortality
in general colour their attitude to a procedure that provides the most graphic evidence possible of death and its consequences. Careful and sensitive incorporation of the autopsy into programmes designed to teach students about dying and death might help to reduce students' antipathy to both, and provide the autopsy with yet another indispensible role.
EMYRW. BENBOW Department ofPathologica1 Sciences University ojhfanchester Manchester A413 9PT, U.K.
REFERENCES I . Hill RB. Anderson RE. The Autopsy-Medical Practice and Public Policy. Boston: Butterworths, 1988: 56-64. 2 Anderson RE. Hill RB. The autopsy in academic medical cemers in the United States. Hum Purhol 1988; 1 9 1369-1371. 3. Anderson RE. Hill RB. Epitome. The current status of the autopsy in academic medical centers in the United Statea An1 J Clin Purlid 1989. 92: s31-537. 4. Benbow EW. Medical students' views on the autopsy. J Clin Parhul (in press). 5 . Benbow EW. Autopsy demonstrations to medical students: audit by questionnaire. J Paihul1990: 162 177-180. 6. Benbow EW. A questionnaire survey of the attitudes of second and third year medical students to the autopsy (Abstract) J Parhul 1990; 161: 349A. 7 Anderson RE. Fox RC. Hill RB. Medical uncertainty and the autopsy: occult benefits for students. Hum Parhol 1990; 21: 128-135.
