Forensic Science International 113 (2000) 303308

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The attitudes of medical students to autopsy

a, b ~ *, M.S M.A. Inanc . Sozen , N. Alkan b , N. Arcan b , M.E. Aksoy a
a

Marmara University Faculty of Medicine, Forensic Medicine Department, Tbbye Cad. No:49, 81326 Haydarpas a, Istanbul, Turkey b~ Istanbul University, Istanbul Faculty of Medicine, Forensic Medicine Department, C apa, Istanbul, Turkey

Abstract To assess the attitudes of medical students to autopsy, 6th year students in the Medical Schools located in ~ Istanbul, Edirne and Bursa in Turkey were asked to participate in a questionnaire. In the questionnaire, the main questions were on the number of autopsies they had attended, the number of autopsies they had participated in, their reaction to the rst autopsy, whether they felt the conditions were adequate or not and what would their objectives be upon deciding to perform an autopsy. In the evaluation, it was detected that most of the participants had attended an autopsy, only a minority had participated in autopsy and most of them felt uncomfortable and inadequate on performing autopsy. The results were discussed with respect to the literature. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Autopsy; Medical student; Attitude; Medical education

1. Introduction In Turkey, most of the medical graduates work as general practitioners. According to the statistics of the Turkish Medical Association, the number of general practitioners is about 40 000 and 4500 students graduate from 47 medical schools each year [1]. The Legal Medicine Act No. 3 states that one of the duties of a general practitioner is to provide a legal report as a forensic physician [2] and The Methods of Criminal Judgment Act No. 79 states that an autopsy must be performed by two medical doctors. One of them has to be a forensic medicine specialist or a pathologist. If an autopsy is required inspite of those specialists not being present, it can only be performed by a medical doctor [3]. In general, throughout Turkey a general practitioner often performs forensic autopsy [4] and examines
*Corresponding author. Tel.: 190-216-348-0524; fax: 190216-414-4731. Inanc). E-mail address: inanici@marun.edu.tr (M.A. ~

legal cases because there are not enough forensic medicine specialists [5]. Undergraduate forensic medicine education must be taken by every medical student in Turkey [46]. The topics of the lectures on forensic medicine and autopsy differ in the different medical schools. There is no standard education [4,5]. In 1846, the rst autopsy was performed by Dr Carl Ambros Bernard from Austria, who at the same time was the rst lecturer on forensic medicine in 1839 at the rst medical school in Turkey [7]. Nowadays, the tanatology and postmortem examination are main topics in forensic medicine lectures and training. The aim of this study was to asses the attitudes of medical students to autopsy and discuss them with respect to the literature.

2. Material and methods Sixth-year medical students who had just nished

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Table 1 The courses on the forensic medicine within the medical schools applied to for this study Name of the medical schools Marmara University, Faculty of Medicine (Istanbul) ~ Istanbul University, ~ Istanbul Faculty of Medicine ~ Istanbul University, Cerrahpas a Faculty of Medicine University, Uludag Faculty of Medicine (Bursa) Trakya University, Faculty of Medicine (Edirne) The courses of forensic medicine Sixteen lectures of 80 min each are given to the 5th year students and each student has to observe an autopsy Thirty-six lectures of 50 min each are given to the 5th year students and each student has to observe at least three autopsies. Forty-one lectures of 90 min each are given to the 5th year students and each student has to observe six autopsies. Thirty lectures of 40 min each are given to the 5th year students and 6th year students have to observe the autopsies Sixty lectures of 60 min each are given to the 5th year students and each student has to observe the autopsies.

a course on forensic medicine were asked to participate in the study. The lectures and training given during this course and the name of the medical schools are shown in Table 1. The students received a questionnaire of 20 questions. The main questions were about the number of autopsies they had participated in, the number of autopsies they had attended, their reaction to the rst autopsy, whether they felt the conditions were adequate or not and what would their objectives be upon deciding to perform an autopsy (Table 2). A total of 1154 6th year students in ve medical schools located in the Marmara region of Turkey were invited to participate in this survey and 387 students responded to the questionnaire. The number of 6th year students and participants and the names of the medical schools are shown in Fig. 1.

3. Results The age range was from 21 to 32 and the mean age was 23.4, and there were 231 (59.7%) males and females 156 (40.3%). While 21 (5.4%) 6th year students were expecting to be general practitioners, the number of students planning to be specialists or academicians were 243 (62.8%) and 116 (30.0%), respectively. Seven (1.8%) students did not respond to this question. In total, only three of them planned to be forensic medicine specialists. The number of autopsies in which the students had

participated or attended is shown in Fig. 2. Their own reactions and opinions about others reactions to the rst autopsy are shown in Figs. 3 and 4. In the evaluation of the responses to the questions on the physicians attitudes during autopsy and autopsy conditions, the responses of 166 (42.9%) students were that the physicians performing the autopsy were fully adequate. A total of 89 (23.0%) students thought the physicians were inadequate and 49 (12.7%) students stated that the physicians were unhappy about their conditions. The question on insufcient technical instrumentation was answered by 213 (55.0%) students, and 66 (17.1%) of them considered the autopsy conditions adequate, while 13 (3.4%) thought they were acceptable. A total of 374 (96.6%) participants agreed that autopsies should be performed in places with sufcient light, ventilation and instruments, and 227 (58.7%) students stated that forensic autopsies should be performed by a forensic medicine specialist, while 77 (19.9%) students preferred a pathologist. Seventy-three (18.9%) students stated that autopsies could be performed by general practitioners too. The responses to the rest of the questions are presented in Table 3.

4. Discussion and conclusion Autopsy has long been recognized as a valuable educational experience [8]. Autopsy has played, and

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Table 2 Questionnaire Age . . . , Sex . . . , Place of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Which do you plan? General practitioner, specialist, academic career Area of specialization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In how many autopsies have you participate in? None, 12, 36, more than 7 How many autopsies have you attended? None, 12, 36, more than 7 What was your reaction at the rst autopsy? I felt uncomfortable, I felt miserable, I have no idea What reaction did other students show? Interested, uninterested, variable behavior, I have no idea What were the physicians attitudes during the autopsy? Fully adequate, uncomfortable and anxious, inadequate, unhappy of their conditions, I have no idea Do you think that the autopsy conditions were adequate? Acceptable, adequate, technical instrumentation was insufcient, team performing the autopsy was uninformed Do you think that an autopsy should be performed during medical education? Yes, no Do you believe that an autopsy should be performed to determine cause of death? Yes, no Do you believe that an autopsy is necessary to determine the results of medical treatment and its effects? Yes, no Do you believe an autopsy is worthwhile? Yes, no Are you against an autopsy because of your religious beliefs? Yes, no Where and in which conditions should an autopsy be performed? The scene of death, in any place determined by district attorney, in places with sufcient light, ventilation and instruments, I have no idea Who should perform an autopsy? Any general practitioner, pathologist, forensic medicine specialist, any of them, I have no idea Do you think that relatives of the deceased should be allowed to attend the autopsy? Yes, no, I have no idea Do you feel uncomfortable when you perform an autopsy which is against your religious beliefs? Yes, no Do you worry when performing an autopsy that you could make a mistake because you are not ready for it? Yes, no Are you afraid to perform an autopsy? Yes, no When performing an autopsy, do you think that you risk contamination? Yes, no Do you feel comfortable and satised when performing an autopsy which is a part of your professional responsibility? Yes, no Do you feel adequate on performing an autopsy? Yes, no

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1 2 3 4 5 6 7 8 9 10 11 12

13 14 15 16 17 18 19 20

still plays, an important role in medical curriculum [9]. Gall has listed ve purposes served by an autopsy: (1) instruction, (2) correction quality assessment , (3) discovery and investigation, (4) storehouse and (5) handmaiden of the law [10]. Among young doctors, the attitude towards autopsy is strongly inuenced by the medical curriculum [11]. Some colleagues stated that the lectures and practices on autopsy were given during pathology courses in medical schools [8,9,1113]. In Turkey, autopsy is studied in the pathology courses only in a few medical schools. There are only a few lectures on autopsy. As we mentioned above, in Turkey autopsy education, especially the practice of autopsy, are mainly given in the courses of forensic medicine.

Most medical students rst experience about autopsy are during their forensic medicine education. During their pathology courses, students are encouraged to participate in one or more autopsies [8,11]. In our study, while 71 (18.3%) students had not attended an autopsy, 316 (81.7%) had attended one or more autopsies. But, while 307 (79.3%) students had not participated in them 80 (20.7%) students had participated in one or more autopsies (Fig. 2). Autopsy is a valuable educational experience in most of the literature [8,9,1113] and plays a major role in helping medical students get over their uncertainty about autopsy procedure [14]. In our study, 35 (9.05%) of the students considered that

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Fig. 1. The number of 6th year medical students and participants.

autopsy was not necessary for medical education, 93 (24.0%) of them believed that autopsy was not necessary to determine the results of medical treatment and its effects and 17 (4.4%) students believed that autopsy was not worthwhile. In Benhows study, a considerable proportion of students stated that autopsy was valuable [13]. As we mentioned above, most of the medical graduates work as general practitioners and one of the duties of a general practitioner was to perform forensic autopsies in Turkey. A total of 295 (76.2%) students feel inadequate on performing an autopsy,

122 (31.5%) of them feel uncomfortable and unsatised when performing an autopsy which is a part of their professional responsibility and 273 (70.5%) students were afraid to perform an autopsy. The attitudes of the students to autopsy who were Catholic or Protestant had no religious afliation in Botega and co-workers study [11]. It is stated that there are no Catholic or Protestant edicts that forbid autopsy. According to Geller, removal of organs or disgurement of the dead body is generally forbidden in Islam [15]. But in Turkey, depending on opinion of the Department of Religious Affairs dated

Fig. 2. The number of autopsies in which the students had attended and participated in.

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307

Fig. 3. The students reactions at the rst autopsy.

on 19 October, 1968, organ transplantation is permitted [16]. The majority of Turkish population is Muslim. In our survey, 28 (7.2%) students were against autopsy because of their religious beliefs and 50 (12.9%) of them felt uncomfortable when they performed autopsy which was against their religious beliefs. As in most countries, in Turkey autopsies are categorized into two groups: clinical and forensic autopsies. Clinical autopsy is performed with the

consent of the relatives. Forensic autopsy is performed for the investigation of crimes and suspicious deaths according the decision of the local district attorney. Because of this, the consent of the relatives is not taken in forensic autopsy and the general practitioner must perform it [4]. As far as we know, there has been no study in Turkey about the attitudes of medical students towards autopsy. Most of the students were afraid,

Fig. 4. The others reactions at the rst autopsy.

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Table 3 Responses to some questions in the questionnaire Questions Yes N Do you think that autopsy should be performed for medical education? Do you believe that autopsy should be performed to determine the cause of death? Do you believe that an autopsy is necessary to determine the results of medical treatment and its effects? Do you believe an autopsy is worthwhile? Are you against to an autopsy because of your religious beliefs? Do you think that relatives of the deceased can attend the autopsy? Do you think uncomfortable when you perform an autopsy which is against your religious beliefs? Do you worry when performing an autopsy that you could make a mistake because you are not ready for it? Are you afraid to perform an autopsy? When performing an autopsy, do you think that you are in risk of contamination? Do you feel comfortable and satised when performing an autopsy which is a part of your professional responsibility? Do you feel adequate on performing an autopsy? 351 356 293 370 28 44 50 305 110 146 256 60 % 90.7 92.0 75.7 95.6 7.2 11.4 12.9 78.8 28.4 37.7 66.1 15.5 No N 35 30 93 17 359 293 328 80 273 240 122 295 % 9.0 7.8 24.0 4.4 92.8 75.7 84.8 20.7 70.5 62.0 31.5 76.2

felt inadequate or were uncomfortable about autopsy procedures. This implies that more education should be planned on autopsy in the curriculum of medical schools in Turkey.

[6]

Acknowledgements The authors acknowledge the assistance of Assoc. Prof. Dr. Derya Azmak from Forensic Medicine Department at Trakya University and Dr. Recep Fedakar from Forensic Medicine Department at University. Uludag

[7]

[8]

[9] [10] [11]

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